Provider Demographics
NPI:1457863748
Name:BERGSTROM, KEVIN M (LCPC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:MD
Mailing Address - Zip Code:20861-0339
Mailing Address - Country:US
Mailing Address - Phone:800-491-5369
Mailing Address - Fax:301-774-3678
Practice Address - Street 1:12350 HALL SHOP RD
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-9774
Practice Address - Country:US
Practice Address - Phone:800-491-5369
Practice Address - Fax:301-774-3678
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7780101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional