Provider Demographics
NPI:1932140464
Name:BERGSTEN, MELANIE ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:ANNE
Last Name:BERGSTEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6457 REFLECTIONS DR
Mailing Address - Street 2:STE 120
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-2352
Mailing Address - Country:US
Mailing Address - Phone:614-354-1730
Mailing Address - Fax:
Practice Address - Street 1:1717 HERITAGE LAKE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-6067
Practice Address - Country:US
Practice Address - Phone:614-961-2203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5883103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP67229Medicare UPIN