Provider Demographics
NPI:1346615655
Name:BERGDAHL, STEPHEN ALEXANDER (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ALEXANDER
Last Name:BERGDAHL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2936
Mailing Address - Country:US
Mailing Address - Phone:208-883-1144
Mailing Address - Fax:208-883-8062
Practice Address - Street 1:316 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2936
Practice Address - Country:US
Practice Address - Phone:208-883-1144
Practice Address - Fax:208-883-8062
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-203202103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical