Provider Demographics
NPI:1730134578
Name:BERGQUIST, KATHLEEN LEILANI (, MSW, LCSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:LEILANI
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:, MSW, LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9739 MANHEIM LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-6921
Mailing Address - Country:US
Mailing Address - Phone:702-301-3417
Mailing Address - Fax:
Practice Address - Street 1:9739 MANHEIM LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-6921
Practice Address - Country:US
Practice Address - Phone:702-301-3417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5485-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100508688Medicaid