Provider Demographics
NPI:1356481634
Name:BERGMAN, WILLIAM GREGORY (LISW)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:GREGORY
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3869 DARROW RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-2691
Mailing Address - Country:US
Mailing Address - Phone:330-686-2748
Mailing Address - Fax:330-686-2784
Practice Address - Street 1:3869 DARROW RD
Practice Address - Street 2:SUITE 101
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-2691
Practice Address - Country:US
Practice Address - Phone:330-686-2748
Practice Address - Fax:330-686-2784
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-25271041C0700X
OH872291101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBESW05951Medicare ID - Type UnspecifiedSOCIAL WORKER