Provider Demographics
NPI:1730898545
Name:BERGEN, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:BERGEN
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 1:514 E HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5725
Mailing Address - Country:US
Mailing Address - Phone:414-412-9611
Mailing Address - Fax:
Practice Address - Street 1:6426 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-9738
Practice Address - Country:US
Practice Address - Phone:414-412-9611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health