Provider Demographics
NPI:1063536688
Name:BERGSTROM, DOUGLAS ALAN (PHD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ALAN
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 E MERRITT ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2028
Mailing Address - Country:US
Mailing Address - Phone:928-445-3835
Mailing Address - Fax:928-445-7071
Practice Address - Street 1:143 E MERRITT ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2028
Practice Address - Country:US
Practice Address - Phone:928-445-3835
Practice Address - Fax:928-445-7071
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1142103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical