Provider Demographics
NPI:1245635788
Name:BERGMAN, KATIE C (LMHC, MC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:C
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:LMHC, MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2581 HUNTCLIFF LN
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4902
Mailing Address - Country:US
Mailing Address - Phone:850-520-3321
Mailing Address - Fax:850-848-6490
Practice Address - Street 1:2581 HUNTCLIFF LN
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4902
Practice Address - Country:US
Practice Address - Phone:850-520-3321
Practice Address - Fax:850-848-6490
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-863101YP2500X
FLMH17204101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110724100Medicaid