=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609021054
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN MARIE BERGMAN MED., LMHC, NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2008
-----------------------------------------------------
Last Update Date | 02/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2052 CLEMENT ST
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96822-3328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-256-7145
-----------------------------------------------------
Fax | 808-946-4458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 61442
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96839-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-256-7145
-----------------------------------------------------
Fax | 808-946-4458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 19
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------