Provider Demographics
NPI:1942627500
Name:BERGMAN, MIRANDA ANN (LPCC, CADC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ANN
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:LPCC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3149 MEADOWAY CT
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-6717
Mailing Address - Country:US
Mailing Address - Phone:859-609-3893
Mailing Address - Fax:
Practice Address - Street 1:3309 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ERLANGER
Practice Address - State:KY
Practice Address - Zip Code:41018-4047
Practice Address - Country:US
Practice Address - Phone:859-609-3893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY161536101YP2500X
KY170788101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100337850Medicaid