Basic Information
| Provider Information | |||||||||
| NPI: | 1326261793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGSMA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | WILLARD | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1923 MOERLAND CT NW | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495042319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169014304 | ||||||||
| FaxNumber: | 6164510020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1331 LAKE DR SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495061674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597215 | ||||||||
| FaxNumber: | 6164510020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.