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General NPI Number Information
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NPI Number | 1295210540
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Entity Type | Individual
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Provider Name | AMANDA BERGSTROM LCSW
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Gender | Female
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Dates
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Enumeration Date | 10/02/2018
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Last Update Date | 10/02/2018
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Provider Practice Location Address
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Address Line | 6280 E PIMA ST
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City | TUCSON
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State | AZ
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Zip | 85712-3074
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Country | US
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Telephone | 520-329-1250
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Fax |
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Provider Business Mailing Address
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Address Line | 2733 N NORRIS AVE
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City | TUCSON
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State | AZ
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Zip | 85719-3232
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Country | US
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Telephone | 520-360-9670
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-17391
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License Number State | AZ
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