Provider Demographics
NPI:1255079679
Name:BERGMAN, ANNA VIKTORIA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:VIKTORIA
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 1:14 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465-2068
Mailing Address - Country:US
Mailing Address - Phone:802-858-9369
Mailing Address - Fax:
Practice Address - Street 1:14 WILLOW LN
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:VT
Practice Address - Zip Code:05465-2068
Practice Address - Country:US
Practice Address - Phone:802-858-9369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0134606101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health