Provider Demographics
NPI:1851543102
Name:BERGMAN, ELIZABETH RENEE (LICSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RENEE
Last Name:BERGMAN
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 1:4826 CHICAGO AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1001
Mailing Address - Country:US
Mailing Address - Phone:612-827-3028
Mailing Address - Fax:612-823-4993
Practice Address - Street 1:4826 CHICAGO AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-1001
Practice Address - Country:US
Practice Address - Phone:612-827-3028
Practice Address - Fax:612-823-4993
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN023841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical