Healthcare Provider Details

I. General information

NPI: 1851976740
Provider Name (Legal Business Name): KELSIE LEE EMBREY-BERGSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date: 06/21/2023
Reactivation Date: 07/11/2023

III. Provider practice location address

1911 WILLIAMS DR
OXNARD CA
93036-2612
US

IV. Provider business mailing address

125 W KELLY RD
NEWBURY PARK CA
91320-3818
US

V. Phone/Fax

Practice location:
  • Phone: 805-981-9250
  • Fax:
Mailing address:
  • Phone: 805-340-4775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-155990
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: