Provider Demographics
NPI:1407867955
Name:BRENDA L. BERGMAN, PLLC
Entity Type:Organization
Organization Name:BRENDA L. BERGMAN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:218-740-3060
Mailing Address - Street 1:306 W SUPERIOR ST
Mailing Address - Street 2:SUITE 608
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1803
Mailing Address - Country:US
Mailing Address - Phone:218-740-3060
Mailing Address - Fax:218-740-3060
Practice Address - Street 1:306 W SUPERIOR ST
Practice Address - Street 2:SUITE 608
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1803
Practice Address - Country:US
Practice Address - Phone:218-740-3060
Practice Address - Fax:218-740-3060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1730103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN806547100Medicaid
MN61-24268OtherUBH
MN358J1BEOtherBLUE CROSS
MN117597OtherHEALTHPARTNERS