Healthcare Provider Details

I. General information

NPI: 1306365168
Provider Name (Legal Business Name): MELISSA M BERGUM MSW, APSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 KESSEL CT STE 105
MADISON WI
53711-6227
US

IV. Provider business mailing address

25 KESSEL CT STE 105
MADISON WI
53711-6227
US

V. Phone/Fax

Practice location:
  • Phone: 608-280-2700
  • Fax:
Mailing address:
  • Phone: 608-280-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number129958
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number814520
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: