Provider Demographics
NPI:1851976740
Name:EMBREY-BERGSTROM, KELSIE LEE
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:LEE
Last Name:EMBREY-BERGSTROM
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 1:125 W KELLY RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3818
Mailing Address - Country:US
Mailing Address - Phone:805-340-4775
Mailing Address - Fax:
Practice Address - Street 1:1911 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2612
Practice Address - Country:US
Practice Address - Phone:805-981-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2023-07-12
Deactivation Date:2023-06-21
Deactivation Code:
Reactivation Date:2023-07-11
Provider Licenses
StateLicense IDTaxonomies
RBT-21-155990106S00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician