Provider Demographics
NPI:1265762827
Name:BERGVIK, THOMAS ANTON (MA, LPC)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ANTON
Last Name:BERGVIK
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Gender:M
Credentials:MA, LPC
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Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3074 WHITNEY AVE
Mailing Address - Street 2:BUILDING I 2ND FLOOR
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-2391
Mailing Address - Country:US
Mailing Address - Phone:860-305-2764
Mailing Address - Fax:203-287-2404
Practice Address - Street 1:3074 WHITNEY AVE
Practice Address - Street 2:BUILDING I 2ND FLOOR
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-2391
Practice Address - Country:US
Practice Address - Phone:860-305-2764
Practice Address - Fax:203-287-2404
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT2440101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008049135Medicaid