Healthcare Provider Details

I. General information

NPI: 1306088695
Provider Name (Legal Business Name): NATHAN HENRY BERGHORST MA, MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 FORD AVE STE 2A
MODESTO CA
95350-4649
US

IV. Provider business mailing address

935 BAKER DR
RIPON CA
95366-2523
US

V. Phone/Fax

Practice location:
  • Phone: 209-573-1883
  • Fax: 209-521-0156
Mailing address:
  • Phone: 209-573-1883
  • Fax: 209-521-0156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number50812
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: