Basic Information
| Provider Information | |||||||||
| NPI: | 1588842660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERMEA | ||||||||
| FirstName: | ALFONSO | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3815 W FORT ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482161652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138417380 | ||||||||
| FaxNumber: | 3138413730 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109844202 | ||||||||
| FaxNumber: | 8109848896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2008 | ||||||||
| LastUpdateDate: | 06/04/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401010567 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.