Provider Demographics
NPI:1710054101
Name:BERGMAN, DANIEL PAUL (MS, LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:PAUL
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1247 RALEIGH ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-3848
Mailing Address - Country:US
Mailing Address - Phone:920-497-0846
Mailing Address - Fax:
Practice Address - Street 1:1247 RALEIGH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-3848
Practice Address - Country:US
Practice Address - Phone:920-497-0846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3484-125101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40979800Medicaid