Provider Demographics
NPI:1184043168
Name:BECKY BERGTHOLD, LLC
Entity Type:Organization
Organization Name:BECKY BERGTHOLD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD AND ADOLESCENT THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGTHOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:214-693-7646
Mailing Address - Street 1:1702 N COLLINS BLVD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3566
Mailing Address - Country:US
Mailing Address - Phone:214-693-7646
Mailing Address - Fax:
Practice Address - Street 1:1702 N COLLINS BLVD
Practice Address - Street 2:SUITE 190
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3566
Practice Address - Country:US
Practice Address - Phone:214-693-7646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17987101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty