Provider Demographics
NPI:1255433884
Name:BERGDOLL, HAVA (LCSW)
Entity type:Individual
Prefix:
First Name:HAVA
Middle Name:
Last Name:BERGDOLL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 AGNES AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:PA
Mailing Address - Zip Code:19070-1818
Mailing Address - Country:US
Mailing Address - Phone:610-551-2534
Mailing Address - Fax:
Practice Address - Street 1:945 E HAVERFORD RD
Practice Address - Street 2:SUITE 202 A
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3814
Practice Address - Country:US
Practice Address - Phone:610-551-2534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2014-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0131041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2321091000OtherIBC
PA2321091000OtherKEYSTONE
PA7404316OtherAETNA