Provider Demographics
NPI:1356411169
Name:BERGUM, REBECCA T (LPC, CSAC)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:T
Last Name:BERGUM
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SHORTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-2747
Mailing Address - Country:US
Mailing Address - Phone:434-970-2178
Mailing Address - Fax:434-970-2170
Practice Address - Street 1:500 OLD LYNCHBURG RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-6500
Practice Address - Country:US
Practice Address - Phone:434-970-2178
Practice Address - Fax:434-970-2170
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002384101YP2500X
VA0717000523106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11525477OtherCAQH
VA282972OtherANTHEM BCBS