Healthcare Provider Details

I. General information

NPI: 1073120432
Provider Name (Legal Business Name): THE THERAPY ROOM MIND HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/02/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2581 HUNTCLIFF LN
PANAMA CITY FL
32405-4902
US

IV. Provider business mailing address

2581 HUNTCLIFF LN
PANAMA CITY FL
32405-4902
US

V. Phone/Fax

Practice location:
  • Phone: 850-520-3321
  • Fax: 850-848-6490
Mailing address:
  • Phone: 850-520-3321
  • Fax: 850-848-6490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. KATIE C BERGMAN
Title or Position: OWNER, PROVIDER
Credential: LMHC
Phone: 352-362-6141