Provider Demographics
NPI:1558782128
Name:BERGSTROM, RYAN (BCBA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E HILLCREST DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-5828
Mailing Address - Country:US
Mailing Address - Phone:805-379-4000
Mailing Address - Fax:805-435-7440
Practice Address - Street 1:19019 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3253
Practice Address - Country:US
Practice Address - Phone:818-345-2345
Practice Address - Fax:818-758-8015
Is Sole Proprietor?:No
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-11-8218103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst