1710220157 NPI number — DR. FELICIA MARIE BERGMAN PSYD

Table of content: DR. FELICIA MARIE BERGMAN PSYD (NPI 1710220157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710220157 NPI number — DR. FELICIA MARIE BERGMAN PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGMAN
Provider First Name:
FELICIA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ACTON
Provider Other First Name:
FELICIA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710220157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5851 PEARL RD
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
PARMA HEIGHTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44130-2113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-845-9011
Provider Business Mailing Address Fax Number:
440-845-9013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5851 PEARL RD
Provider Second Line Business Practice Location Address:
#305
Provider Business Practice Location Address City Name:
PARMA HEIGHTS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44130-2113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-845-9011
Provider Business Practice Location Address Fax Number:
440-845-9013
Provider Enumeration Date:
04/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  7008 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000812656 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0084889 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: H186570 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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