Provider Demographics
NPI:1710197173
Name:BERGMAN, LINDSAY RAY (LISW-S, LCSW)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:RAY
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:LISW-S, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7239 FERNBANK AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45233-1011
Mailing Address - Country:US
Mailing Address - Phone:601-408-9616
Mailing Address - Fax:
Practice Address - Street 1:190 WILSON RD
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428-6030
Practice Address - Country:US
Practice Address - Phone:601-408-9616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MSC68741041C0700X
OHI1450832SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0173042Medicaid