MEDICARE: GWENDOLYN D BERGSTROM LIMHP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	1154	NE

General Provider Information

NPI Number	:	1629256706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN D BERGSTROM LIMHP

Provider Business Mailing Address
First Line	:	6459 S HOMESTEAD RD
Second Line	:
City	:	NORTH PLATTE
State	:	NE
Zip	:	69101-6979
Country	:	US
Telephone Number	:	308-520-4863
Fax Number	:

Provider Business Practice Location Address
First Line	:	720 N JEFFERS ST
Second Line	:
City	:	NORTH PLATTE
State	:	NE
Zip	:	69101-3021
Country	:	US
Telephone Number	:	308-520-4863
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	04/19/2024

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