Provider Demographics
NPI:1831602218
Name:BERGSTROM, AMY (LPC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N WAYNE AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3239
Mailing Address - Country:US
Mailing Address - Phone:815-575-2014
Mailing Address - Fax:
Practice Address - Street 1:300 N WAYNE AVE APT 5
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3239
Practice Address - Country:US
Practice Address - Phone:815-575-2014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2023-10-31
Deactivation Date:2017-11-08
Deactivation Code:
Reactivation Date:2017-11-14
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MDLC9490101YP2500X
PAPC012237101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health