Provider Demographics
NPI:1770171845
Name:BERGMARK CONSULTING, LLC
Entity type:Organization
Organization Name:BERGMARK CONSULTING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGMARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, BCBA-D, LBA
Authorized Official - Phone:616-251-8162
Mailing Address - Street 1:421 PIONEER TRL
Mailing Address - Street 2:
Mailing Address - City:CEDAR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49319-8136
Mailing Address - Country:US
Mailing Address - Phone:616-251-8162
Mailing Address - Fax:
Practice Address - Street 1:421 PIONEER TRL
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-8136
Practice Address - Country:US
Practice Address - Phone:773-791-9906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1407274608Medicaid