Healthcare Provider Details

I. General information

NPI: 1871900456
Provider Name (Legal Business Name): STEPHANIE BERGMAN MA, LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 07/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 MONROE AVE NW
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

648 MONROE AVE NW STE 100
GRAND RAPIDS MI
49503-6714
US

V. Phone/Fax

Practice location:
  • Phone: 616-901-1429
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014265
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: