Healthcare Provider Details

I. General information

NPI: 1245249747
Provider Name (Legal Business Name): CYNTHIA BERGSTROM DEVLIN L.P.C.C., L.M.F.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 S SAINT FRANCIS DR STE B
SANTA FE NM
87505-4052
US

IV. Provider business mailing address

6 BUENA VENTURA PL
SANTA FE NM
87508-8377
US

V. Phone/Fax

Practice location:
  • Phone: 505-303-3586
  • Fax: 505-303-3586
Mailing address:
  • Phone: 505-303-3586
  • Fax: 505-303-3586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0189951
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0189901
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0189951
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: