Provider Demographics
NPI:1225756216
Name:BERGSTROM, MICHAEL (LAMFT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 N CENTRAL AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2639
Mailing Address - Country:US
Mailing Address - Phone:602-230-7373
Mailing Address - Fax:
Practice Address - Street 1:9014 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-8304
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:602-441-5836
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAMFT-10777106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist