Provider Demographics
NPI:1912029109
Name:BERGAN, CHRISTINE CELESTE (PHD, CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:CELESTE
Last Name:BERGAN
Suffix:
Gender:F
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 S HULEN ST
Mailing Address - Street 2:APT. 1134
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4970
Mailing Address - Country:US
Mailing Address - Phone:319-530-7469
Mailing Address - Fax:
Practice Address - Street 1:4141 S HULEN ST
Practice Address - Street 2:APT. 1134
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4970
Practice Address - Country:US
Practice Address - Phone:319-530-7469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01459235Z00000X
TX106342235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX106342OtherTEXAS STATE LICENSE-SPEECH-LANGUAGE PATHOLOGIST