Douglas Alan Bergstrom, PH.D.
Individual provider Active NPI Clinical Psychologist · Prescott, AZ
NPI 1063536688 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1063536688
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Clinical Psychologist 103TC0700X
- License
- 1142 (AZ)
- Practice address
- 143 E Merritt St
Prescott, AZ 86301-2028 - Phone
- (928) 445-3835
- Fax
- (928) 445-7071
- NPI assigned
- Mar 19, 2007
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare Care Compare profile
- Specialty
- Clinical Psychologist
- Education
- Other, 1983
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Telehealth
- Offers telehealth services
Practice addresses (Care Compare)
1680 W Iron Springs Rd
Suite 101
Prescott, AZ 86305-3313
Phone (520) 369-3885
4735 Cody Dr
Prescott, AZ 86305-7479
Phone (520) 369-3885
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20051005000081 | AZ | Practitioner - Clinical Psychologist | 9931134327 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1142 | AZ | MD | Clinical Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Douglas a. Bergstrom, PH.D., PLLC | Current |
Accepting new patients |
Locations
143 E Merritt St
Prescott, AZ 86301
Phone (928) 445-5027
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 1142 | AZ | Yes |
Addresses
Primary practice location
143 E Merritt St
Prescott, AZ 86301-2028
Mailing address
143 E Merritt St
Prescott, AZ 86301-2028
Phone (928) 445-3835
Other providers in Prescott, AZ
- Anne M Benson
- Bradley Vernon Benson
- Brian David Benson
- Eric Bequary
- August Henry Bergman
- Michael Berlowe
- Melanie Corinne Bernal
- Brian Zachary Bernier
- Andrea Bernkrant
- Amy Renee Berry
All providers in Prescott, AZ · Clinical Psychologist in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.