Provider Demographics
NPI:1659879849
Name:BERGMAN, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:OH
Mailing Address - Zip Code:43430-1411
Mailing Address - Country:US
Mailing Address - Phone:419-461-1983
Mailing Address - Fax:
Practice Address - Street 1:635 MAIN ST
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:OH
Practice Address - Zip Code:43430-1635
Practice Address - Country:US
Practice Address - Phone:419-461-1983
Practice Address - Fax:419-461-3516
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1800896101YM0800X
OHE.2001932101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0266112Medicaid