Provider Demographics
NPI:1730352006
Name:BERGMAN, MIRANDA (MFP, LBP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:MFP, LBP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 S HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-5958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2512 S HARVEY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-5958
Practice Address - Country:US
Practice Address - Phone:405-595-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health