Provider Demographics
NPI:1588978332
Name:BERGESON, STEPHANIE KAY
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:KAY
Last Name:BERGESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1963 S 1130 W
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-2320
Mailing Address - Country:US
Mailing Address - Phone:801-707-9612
Mailing Address - Fax:
Practice Address - Street 1:94 E PAGES LN
Practice Address - Street 2:A
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-2216
Practice Address - Country:US
Practice Address - Phone:801-294-0578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool