Healthcare Provider Details

I. General information

NPI: 1215609797
Provider Name (Legal Business Name): ERIN M BERGREN MS.ED., LCPC, ACS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5290 WILLIAMS DR
ROSCOE IL
61073-9222
US

IV. Provider business mailing address

229 MARTIN ST
SHARON WI
53585-9617
US

V. Phone/Fax

Practice location:
  • Phone: 262-607-1234
  • Fax:
Mailing address:
  • Phone: 102-626-0712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.010642
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: