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General NPI Number Information
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NPI Number | 1811125974
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Entity Type | Individual
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Provider Name | LARA M BERGSTEDT LCSW
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Gender | Female
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Dates
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Enumeration Date | 06/29/2009
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Last Update Date | 04/22/2021
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Provider Practice Location Address
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Address Line | 323 W MULBERRY ST
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City | WATSEKA
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State | IL
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Zip | 60970-1568
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Country | US
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Telephone | 815-432-5241
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Fax |
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Provider Business Mailing Address
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Address Line | 3446 191ST ST
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City | LANSING
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State | IL
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Zip | 60438-3848
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Country | US
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Telephone | 708-837-8377
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LSW0000006090
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34008657A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.013607
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License Number State | IL
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