Provider Demographics
NPI:1972835601
Name:BERGUM, TAMARA E (MFT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:E
Last Name:BERGUM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15655 W COUNTY ROAD B
Mailing Address - Street 2:P.O. BOX 13251
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2680
Mailing Address - Country:US
Mailing Address - Phone:715-634-0607
Mailing Address - Fax:715-634-0617
Practice Address - Street 1:15655 W COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-3251
Practice Address - Country:US
Practice Address - Phone:715-634-0607
Practice Address - Fax:715-634-0617
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI141-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI141-228OtherWI DRL