Provider Demographics
NPI:1629256706
Name:BERGSTROM, GWENDOLYN D (LIMHP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:D
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6459 S HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6979
Mailing Address - Country:US
Mailing Address - Phone:308-520-4863
Mailing Address - Fax:
Practice Address - Street 1:720 N JEFFERS ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-3021
Practice Address - Country:US
Practice Address - Phone:308-520-4863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1154101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health