Provider Demographics
NPI:1265907943
Name:BERGEN, TAMMY LEE
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:LEE
Last Name:BERGEN
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 1:22 US OVAL STE 100
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12903-5901
Mailing Address - Country:US
Mailing Address - Phone:518-578-1442
Mailing Address - Fax:
Practice Address - Street 1:22 US OVAL STE 100
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12903-5901
Practice Address - Country:US
Practice Address - Phone:518-578-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP13611101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral