Basic Information
| Provider Information | |||||||||
| NPI: | 1013467562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGERSON | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERGERSON | ||||||||
| OtherFirstName: | KARI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15305 RAYEN ST | ||||||||
| Address2: | |||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913435117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188923423 | ||||||||
| FaxNumber: | 8188934509 | ||||||||
| Practice Location | |||||||||
| Address1: | 15305 RAYEN ST | ||||||||
| Address2: | |||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913435117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188923423 | ||||||||
| FaxNumber: | 8188934509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2016 | ||||||||
| LastUpdateDate: | 06/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 94852 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 113530 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 95-2633765 | 01 | CA | MEDI-CAL | OTHER |