Provider Demographics
NPI:1972001410
Name:BERGMAN, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
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 1:43 STAG DR
Mailing Address - Street 2:
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01821-4115
Mailing Address - Country:US
Mailing Address - Phone:978-430-0768
Mailing Address - Fax:
Practice Address - Street 1:20 MAIN ST
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3575
Practice Address - Country:US
Practice Address - Phone:978-263-1427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician