Provider Demographics
NPI:1609021054
Name:BERGMAN, SUSAN MARIE (MED, LMHC, NCC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:MED, LMHC, NCC
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:KNIEBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:PO BOX 61442
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96839-1442
Mailing Address - Country:US
Mailing Address - Phone:808-256-7145
Mailing Address - Fax:808-946-4458
Practice Address - Street 1:2052 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96822-3328
Practice Address - Country:US
Practice Address - Phone:808-256-7145
Practice Address - Fax:808-946-4458
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-27
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI19101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health