Provider Demographics
NPI:1629320239
Name:BERGONDO, MICHAEL ALVIN (MSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALVIN
Last Name:BERGONDO
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 FOWLER ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3927
Mailing Address - Country:US
Mailing Address - Phone:719-269-9296
Mailing Address - Fax:
Practice Address - Street 1:1100 CARSON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2751
Practice Address - Country:US
Practice Address - Phone:719-383-5195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9929471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical