Provider Demographics
NPI:1568940211
Name:BERGH, FREDERICK DOUGLAS I (PPC)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:DOUGLAS
Last Name:BERGH
Suffix:I
Gender:M
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-6247
Mailing Address - Country:US
Mailing Address - Phone:720-484-1961
Mailing Address - Fax:
Practice Address - Street 1:1541 DIAMOND DR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-6247
Practice Address - Country:US
Practice Address - Phone:720-484-1961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPAT-084101YA0400X
WYPPC-1120101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)