Provider Demographics
NPI:1578246690
Name:MB PSYCHOLOGY PLLC
Entity Type:Organization
Organization Name:MB PSYCHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA BERGQUIST, L
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:CLINICAL PSYCHOLOGIS
Authorized Official - Phone:716-481-6259
Mailing Address - Street 1:40 GARDENVILLE PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1387
Mailing Address - Country:US
Mailing Address - Phone:716-794-4054
Mailing Address - Fax:716-794-4054
Practice Address - Street 1:40 GARDENVILLE PKWY STE 112
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1387
Practice Address - Country:US
Practice Address - Phone:716-794-4054
Practice Address - Fax:716-794-4054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty