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General NPI Number Information
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NPI Number | 1760134910
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Entity Type | Individual
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Provider Name | KEVIN JAY BERGSTROM
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Gender | Male
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Dates
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Enumeration Date | 01/19/2022
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Last Update Date | 01/19/2022
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Provider Practice Location Address
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Address Line | 1221 W 17TH ST
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City | NORTH PLATTE
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State | NE
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Zip | 69101-2216
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Country | US
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Telephone | 308-380-9196
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Fax |
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Provider Business Mailing Address
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Address Line | 6459 S HOMESTEAD RD
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City | NORTH PLATTE
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State | NE
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Zip | 69101-6979
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Country | US
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Telephone | 308-380-9196
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 12870
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License Number State | NE
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