Healthcare Provider Details

I. General information

NPI: 1245635788
Provider Name (Legal Business Name): KATIE C BERGMAN LMHC, MC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
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 NumberPPC-863
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH17204
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: