Healthcare Provider Details

I. General information

NPI: 1225756216
Provider Name (Legal Business Name): MICHAEL BERGSTROM LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 W GUADALUPE RD STE 6
MESA AZ
85202-7366
US

IV. Provider business mailing address

3101 N CENTRAL AVE STE 550
PHOENIX AZ
85012-2635
US

V. Phone/Fax

Practice location:
  • Phone: 602-230-7373
  • Fax: 480-628-8577
Mailing address:
  • Phone: 602-230-7373
  • Fax: 602-682-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT-16517
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLAMFT-10777
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: