Healthcare Provider Details

I. General information

NPI: 1942089636
Provider Name (Legal Business Name): BREANNA YBELTJE BERGEVIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 S COLE RD
BOISE ID
83709-0932
US

IV. Provider business mailing address

148 S COLE RD
BOISE ID
83709-0932
US

V. Phone/Fax

Practice location:
  • Phone: 208-683-8320
  • Fax: 208-969-8380
Mailing address:
  • Phone: 208-683-8320
  • Fax: 208-969-8380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number45391
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number45391
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: