Provider Demographics
NPI:1346523743
Name:BERGQUIST, BETSY S (MA LMHC)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:S
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COOPER POINT RD SW
Mailing Address - Street 2:BLDG 17
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-1178
Mailing Address - Country:US
Mailing Address - Phone:908-329-5877
Mailing Address - Fax:
Practice Address - Street 1:1800 COOPER POINT RD SW
Practice Address - Street 2:BLDG 17
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1178
Practice Address - Country:US
Practice Address - Phone:908-329-5877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00005791101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00005791OtherWASHINGTON STATE DEPARTMENT OF HEALTH LMHC LICENSE#