Provider Demographics
NPI:1255622932
Name:BERGSTROM, LORI MARIE (MA)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:MARIE
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:MARIE
Other - Last Name:BERGSTROM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:28456 CONSTELLATION RD
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-5081
Mailing Address - Country:US
Mailing Address - Phone:661-458-8006
Mailing Address - Fax:866-373-8006
Practice Address - Street 1:28456 CONSTELLATION RD
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5081
Practice Address - Country:US
Practice Address - Phone:661-458-8006
Practice Address - Fax:866-373-8006
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 39726106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist