Provider Demographics
NPI:1194325159
Name:BERGSTROM, TATIANA L (MA, LSATP)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:L
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:MA, LSATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 PRINCE WILLIAM PKWY STE 301
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-7667
Mailing Address - Country:US
Mailing Address - Phone:703-688-8541
Mailing Address - Fax:703-213-5025
Practice Address - Street 1:4001 PRINCE WILLIAM PKWY STE 301
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-7667
Practice Address - Country:US
Practice Address - Phone:703-688-8541
Practice Address - Fax:703-213-5025
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000337101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)