Provider Demographics
NPI:1942089636
Name:BERGEVIN, BREANNA YBELTJE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:YBELTJE
Last Name:BERGEVIN
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 1:9352B ARTHUR KRAUSE LOOP
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648-5332
Mailing Address - Country:US
Mailing Address - Phone:209-588-6660
Mailing Address - Fax:
Practice Address - Street 1:1140 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2821
Practice Address - Country:US
Practice Address - Phone:208-580-5431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling