Provider Demographics
NPI:1427055995
Name:BERGESON, KATHLEEN RAE (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:RAE
Last Name:BERGESON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 REITZ BLVD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9293
Mailing Address - Country:US
Mailing Address - Phone:570-524-0881
Mailing Address - Fax:570-524-9738
Practice Address - Street 1:11 REITZ BLVD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9293
Practice Address - Country:US
Practice Address - Phone:570-524-0881
Practice Address - Fax:570-524-9738
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012260103G00000X
PAPS015237103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA055893Medicare ID - Type Unspecified
PAR97609Medicare UPIN