Provider Demographics
NPI:1407961311
Name:BERGEN, VICKIE LYNN (PHD LP)
Entity Type:Individual
Prefix:DR
First Name:VICKIE
Middle Name:LYNN
Last Name:BERGEN
Suffix:
Gender:F
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38284 KLARR DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167
Mailing Address - Country:US
Mailing Address - Phone:248-476-6885
Mailing Address - Fax:
Practice Address - Street 1:20600 EUREKA ROAD
Practice Address - Street 2:SUITE 819
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180
Practice Address - Country:US
Practice Address - Phone:734-285-8282
Practice Address - Fax:734-281-0402
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008768103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ24542009Medicare ID - Type Unspecified