Provider Demographics
NPI:1871528398
Name:BERGMAN, GISELA H (EDD)
Entity type:Individual
Prefix:
First Name:GISELA
Middle Name:H
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 OAK ALY
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-3692
Mailing Address - Country:US
Mailing Address - Phone:541-345-4019
Mailing Address - Fax:541-345-2834
Practice Address - Street 1:2791 OAK ALY
Practice Address - Street 2:SUITE 1B
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-3692
Practice Address - Country:US
Practice Address - Phone:541-345-4019
Practice Address - Fax:541-345-2834
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR550103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000TCHVSMedicare ID - Type UnspecifiedMEDICARE NUMBER