Provider Demographics
NPI:1407545676
Name:BERGKOETTER, LISA DIANE (MSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:BERGKOETTER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DIANE
Other - Last Name:KNAKAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10635 DUNHAM RD
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48353-1017
Mailing Address - Country:US
Mailing Address - Phone:248-310-4236
Mailing Address - Fax:
Practice Address - Street 1:10635 DUNHAM RD
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-1017
Practice Address - Country:US
Practice Address - Phone:248-310-4236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511147691041C0700X, 1041S0200X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool