Healthcare Provider Details

I. General information

NPI: 1639626294
Provider Name (Legal Business Name): KAI BERGONDI BLAKE M.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 15TH ST SE
WASHINGTON DC
20020
US

IV. Provider business mailing address

7800 POMFRET RD
POMFRET MD
20675-3218
US

V. Phone/Fax

Practice location:
  • Phone: 240-412-8260
  • Fax:
Mailing address:
  • Phone: 240-412-8260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number10993888
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: