Provider Demographics
NPI:1528093820
Name:BERGMAN, RONNIE LINDSEY (PHD)
Entity type:Individual
Prefix:
First Name:RONNIE
Middle Name:LINDSEY
Last Name:BERGMAN
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-301-8708
Mailing Address - Fax:310-301-8751
Practice Address - Street 1:760 WESTWOOD PLAZA
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8358
Practice Address - Country:US
Practice Address - Phone:310-825-9989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15589103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY155890Medicaid
CAPSY155890Medicaid