Provider Demographics
NPI:1902124910
Name:BERGSTROM, BJORN PAUL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BJORN
Middle Name:PAUL
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 SW MORRISON ST STE 619
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2217
Mailing Address - Country:US
Mailing Address - Phone:503-780-3723
Mailing Address - Fax:
Practice Address - Street 1:1130 SW MORRISON ST
Practice Address - Street 2:SUITE 619
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2234
Practice Address - Country:US
Practice Address - Phone:503-780-3723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
OR2444103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program