MEDICARE: CYNTHIA BERGSTROM DEVLIN L.P.C.C., L.M.F.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	0189951	NM
2	106H00000X	Marriage & Family Therapist	0189901	NM
3	101YP2500X	Professional Counselor	0189951	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	223065	OTHER	VA	ANTHEM BC/BS

General Provider Information

NPI Number	:	1245249747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CYNTHIA BERGSTROM DEVLIN L.P.C.C., L.M.F.T.

Provider Business Mailing Address
First Line	:	6 BUENA VENTURA PL
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87508-8377
Country	:	US
Telephone Number	:	505-303-3586
Fax Number	:	505-303-3586

Provider Business Practice Location Address
First Line	:	1229 S SAINT FRANCIS DR STE B
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4052
Country	:	US
Telephone Number	:	505-303-3586
Fax Number	:	505-303-3586

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/21/2022

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