Provider Demographics
NPI:1265847958
Name:BERGMAN, GWENDOLYN LOUISE
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:LOUISE
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 EAST BROADWAY ST. LOT 49
Mailing Address - Street 2:
Mailing Address - City:FORT
Mailing Address - State:OH
Mailing Address - Zip Code:45846
Mailing Address - Country:US
Mailing Address - Phone:419-953-1789
Mailing Address - Fax:
Practice Address - Street 1:117 E BROADWAY ST LOT 49
Practice Address - Street 2:
Practice Address - City:FORT RECOVERY
Practice Address - State:OH
Practice Address - Zip Code:45846-9318
Practice Address - Country:US
Practice Address - Phone:419-953-1789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-22
Last Update Date:2014-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3128822103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst