Provider Demographics
NPI:1548591241
Name:BERGMANN, KATHIE A
Entity Type:Individual
Prefix:
First Name:KATHIE
Middle Name:A
Last Name:BERGMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7949
Mailing Address - Country:US
Mailing Address - Phone:918-787-2104
Mailing Address - Fax:918-787-2106
Practice Address - Street 1:905 E 3RD ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-7949
Practice Address - Country:US
Practice Address - Phone:918-787-2104
Practice Address - Fax:918-787-2106
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor