Provider Demographics
NPI:1356613186
Name:DR. BERGIN PSYCHOTHERAPY FAMILY SERVICE,PC
Entity type:Organization
Organization Name:DR. BERGIN PSYCHOTHERAPY FAMILY SERVICE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERGIN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:951-684-6684
Mailing Address - Street 1:17130 VAN BUREN BLVD # 341
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-5905
Mailing Address - Country:US
Mailing Address - Phone:951-684-6684
Mailing Address - Fax:951-684-7503
Practice Address - Street 1:6800 INDIANA AVE STE 130
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4266
Practice Address - Country:US
Practice Address - Phone:951-684-6684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40818106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA40818OtherLICENSE NUMBER