Healthcare Provider Details

I. General information

NPI: 1659879849
Provider Name (Legal Business Name): ELIZABETH BERGMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 08/03/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 MAIN ST
GENOA OH
43430-1635
US

IV. Provider business mailing address

217 E 11TH ST
GENOA OH
43430-1411
US

V. Phone/Fax

Practice location:
  • Phone: 419-461-1983
  • Fax: 419-461-3516
Mailing address:
  • Phone: 419-461-1983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.1800896
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2001932
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: