Provider Demographics
NPI:1164074241
Name:BERGQUIST, AMANDA LISSNER
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LISSNER
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01036-9640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 BEECH ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-3968
Practice Address - Country:US
Practice Address - Phone:413-540-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5000774101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1851444616OtherRIVER VALLEY COUNSELING CENTER