Healthcare Provider Details

I. General information

NPI: 1225604861
Provider Name (Legal Business Name): MARISA LOUISE BERGFIELD M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISA BERGFIELD MICHIELS M.A.

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 W RIVER ST STE 11A
PROVIDENCE RI
02904-2609
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-8770
  • Fax: 401-793-8709
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS02209
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: