Provider Demographics
NPI:1174908321
Name:BERGLAND, PHIL (LPC)
Entity type:Individual
Prefix:
First Name:PHIL
Middle Name:
Last Name:BERGLAND
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15114 NE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-8108
Mailing Address - Country:US
Mailing Address - Phone:360-980-2326
Mailing Address - Fax:
Practice Address - Street 1:11220 SE STARK ST
Practice Address - Street 2:SUITE 6
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216
Practice Address - Country:US
Practice Address - Phone:503-908-4681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3611101YM0800X
WALH60618681101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional