Provider Demographics
NPI:1477795292
Name:BERGSTROM, PATRICIA S (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:S
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:S
Other - Last Name:HERKLOTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:57 WATER STREET
Mailing Address - Street 2:
Mailing Address - City:BLUE HILL
Mailing Address - State:ME
Mailing Address - Zip Code:04614
Mailing Address - Country:US
Mailing Address - Phone:207-374-2311
Mailing Address - Fax:207-374-3991
Practice Address - Street 1:57 WATER STREET
Practice Address - Street 2:
Practice Address - City:BLUE HILL
Practice Address - State:ME
Practice Address - Zip Code:04614
Practice Address - Country:US
Practice Address - Phone:207-374-2311
Practice Address - Fax:207-374-3991
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC1463101YA0400X
MELC57011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1477795292Medicaid
ME0011824Medicare PIN