Provider Demographics
NPI:1174144000
Name:BERGSTROM, MELISSA KIERSTEN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:KIERSTEN
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:KIERSTEN
Other - Last Name:BERGSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 SONORA ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5207
Mailing Address - Country:US
Mailing Address - Phone:626-476-0929
Mailing Address - Fax:
Practice Address - Street 1:572 N ARROWHEAD AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1251
Practice Address - Country:US
Practice Address - Phone:909-266-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120224104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker