Provider Demographics
NPI:1598776387
Name:BERGMAN, BRENDA LOUISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:LOUISE
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W SUPERIOR ST
Mailing Address - Street 2:SUITE 608
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1803
Mailing Address - Country:US
Mailing Address - Phone:218-740-3060
Mailing Address - Fax:218-740-3070
Practice Address - Street 1:306 W SUPERIOR ST
Practice Address - Street 2:SUITE 608
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1803
Practice Address - Country:US
Practice Address - Phone:218-740-3060
Practice Address - Fax:218-740-3070
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1730103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN806547100Medicaid
MN358J2BEOtherBLUE CROSS
MN61-24268OtherMEDICA