Provider Demographics
NPI:1164287587
Name:BERGSTROM, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TORREY
Other - Middle Name:
Other - Last Name:BERGSTROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:310 REGENCY PKWY
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3791
Mailing Address - Country:US
Mailing Address - Phone:515-207-5251
Mailing Address - Fax:
Practice Address - Street 1:310 REGENCY PKWY
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3791
Practice Address - Country:US
Practice Address - Phone:515-207-5251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician