Healthcare Provider Details

I. General information

NPI: 1710054101
Provider Name (Legal Business Name): DANIEL PAUL BERGMAN M.S., L.P.C., N.C.C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1247 RALEIGH ST
GREEN BAY WI
54304-3848
US

IV. Provider business mailing address

1247 RALEIGH ST
GREEN BAY WI
54304-3848
US

V. Phone/Fax

Practice location:
  • Phone: 920-497-0846
  • Fax:
Mailing address:
  • Phone: 920-497-0846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3484-125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3484-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: