Provider Demographics
NPI:1659086601
Name:BERGERSON, MI JA KANG (LICSW)
Entity Type:Individual
Prefix:
First Name:MI JA
Middle Name:KANG
Last Name:BERGERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2385 CHATEAU LN
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1750
Mailing Address - Country:US
Mailing Address - Phone:612-743-7893
Mailing Address - Fax:
Practice Address - Street 1:2385 CHATEAU LN
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-1750
Practice Address - Country:US
Practice Address - Phone:612-743-7893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN287701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical