Provider Demographics
NPI:1427066828
Name:BERGSTROM, MATTHEW JAY
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JAY
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32922 JOHNSTON LN
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-6315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 N.W. BOARDMAN AVE.
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OR
Practice Address - Zip Code:97818
Practice Address - Country:US
Practice Address - Phone:541-481-2911
Practice Address - Fax:541-481-2006
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional