Provider Demographics
NPI:1912068834
Name:BERGMAN, KATHLEEN G (MA LP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:G
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:MS
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:BERGMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:10267 UNIV AVE N
Mailing Address - Street 2:ST 203
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434
Mailing Address - Country:US
Mailing Address - Phone:612-210-0367
Mailing Address - Fax:763-786-5462
Practice Address - Street 1:10267 UNIV AVE N
Practice Address - Street 2:ST 203
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434
Practice Address - Country:US
Practice Address - Phone:612-210-0367
Practice Address - Fax:763-786-5462
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1469103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist