Provider Demographics
NPI:1043728363
Name:BERGSTUE, MARY JOAN (MA, ALC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JOAN
Last Name:BERGSTUE
Suffix:
Gender:F
Credentials:MA, ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 WILLOWBROOK DR SE STE B
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-3262
Mailing Address - Country:US
Mailing Address - Phone:256-361-9733
Mailing Address - Fax:
Practice Address - Street 1:915 WILLOWBROOK DR SE STE B
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-3262
Practice Address - Country:US
Practice Address - Phone:256-361-9733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2014A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional