Provider Demographics
NPI:1053787135
Name:BERGAMINI, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BERGAMINI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 OLD BALLAS RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7051
Mailing Address - Country:US
Mailing Address - Phone:314-569-2253
Mailing Address - Fax:
Practice Address - Street 1:711 OLD BALLAS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7051
Practice Address - Country:US
Practice Address - Phone:314-569-2253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140287271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical