Provider Demographics
NPI:1710668470
Name:BERGLUND, SHAUNA RENEE
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:RENEE
Last Name:BERGLUND
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 1:11710 SEA STAR WAY
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9617
Mailing Address - Country:US
Mailing Address - Phone:317-509-6873
Mailing Address - Fax:
Practice Address - Street 1:3497 CONNER ST
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-2414
Practice Address - Country:US
Practice Address - Phone:317-942-0772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34010491A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical