Douglas a. Bergstrom, PH.D., PLLC
Organization Active NPI Community/Behavioral Health Agency · Prescott, AZ
NPI 1154501682 · NPPES record last updated Nov 13, 2007
Key facts
- NPI
- 1154501682
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Behavioral Health Agency 251S00000X
- License
- 1142 (AZ)
- Legal business name
- DOUGLAS A. BERGSTROM, PH.D., PLLC
- Practice address
- 143 E Merritt St
Prescott, AZ 86301-2028 - Phone
- (928) 445-3835
- Fax
- (928) 445-7071
- NPI assigned
- Nov 13, 2007
- Organization subpart
- No
Authorized official
- Name
- Douglas Alan Bergstrom, PH.D.
- Title
- Psychologist
- Phone
- (928) 445-3835
Practitioners 2
-
Douglas Alan Bergstrom, PH.D.
-
Esther N Greenwald, P.T.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20071129000057 | AZ | Part B Supplier - Clinic/Group Practice | 2860581816 |
Receives reassigned benefits from 1 practitioner Practice locations: Prescott, AZ |
National Provider Directory
Locations
143 E Merritt St
Prescott, AZ 86301
Phone (928) 445-5027
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Behavioral Health Agency | 251S00000X | 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
- Silvana Martins Lourenco Domaz
- Joseph Donaldson
- Robert Louis Donaldson
- Mary Colleen Donnelly
- Heather Anne Donovan
- Douglas L Shepard MD PA
- Brandon Gregory Dowler
- Crystal Downer
- Samuel William Downing V
- Kevin S Doyle
All providers in Prescott, AZ · Community/Behavioral Health Agency in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 13, 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.