Provider Demographics
NPI:1508221318
Name:BERGDAHL, ELISABETH ERIN WAGNER
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:ERIN WAGNER
Last Name:BERGDAHL
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 1:17330 135TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-8522
Mailing Address - Country:US
Mailing Address - Phone:425-998-9769
Mailing Address - Fax:
Practice Address - Street 1:17330 135TH AVE NE
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-8522
Practice Address - Country:US
Practice Address - Phone:425-998-9769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC 60724657101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health