Provider Demographics
NPI:1497856637
Name:BERGEN, SUSAN DIANE (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:BERGEN
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 LONG ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3096
Mailing Address - Country:US
Mailing Address - Phone:208-735-1561
Mailing Address - Fax:208-736-4400
Practice Address - Street 1:647 FILER AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4008
Practice Address - Country:US
Practice Address - Phone:208-737-9999
Practice Address - Fax:208-736-4400
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT-2962106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010157599OtherREGENCE BLUE SHIELD