Provider Demographics
NPI:1487892311
Name:VICKIE L. BERGEN, PHD, PLLC
Entity type:Organization
Organization Name:VICKIE L. BERGEN, PHD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-444-7711
Mailing Address - Street 1:25882 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-1292
Mailing Address - Country:US
Mailing Address - Phone:248-444-7711
Mailing Address - Fax:
Practice Address - Street 1:25882 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-1292
Practice Address - Country:US
Practice Address - Phone:248-444-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008768103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty