| Doctor Name: | DOUGLAS ALAN BERGSTROM |
| NPI Number: | 1063536688 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PH.D. |
| License Number: | 1142 |
| Business Practice Address: | 143 E Merritt St Prescott, AZ - 863012028 |
| Business Phone Number: | 9284453835 |
| Business Fax Number: | 9284457071 |
| Mailing Address: | 143 E Merritt St, PRESCOTT |
| State: | AZ |
| Postal Code: | 863012028 |
| Phone Number: | 9284453835 |
| Fax Number: | 9284457071 |
| NPI Enumeration Date: | 03/19/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 1142 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AZ |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |