Provider Demographics
NPI:1013081637
Name:CAMILLA O. BERGSTROM LCSW PC
Entity Type:Organization
Organization Name:CAMILLA O. BERGSTROM LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CAMILLA
Authorized Official - Middle Name:O
Authorized Official - Last Name:HURD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:406-736-5613
Mailing Address - Street 1:533 EVANS RICEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BELT
Mailing Address - State:MT
Mailing Address - Zip Code:59412-8400
Mailing Address - Country:US
Mailing Address - Phone:406-736-5613
Mailing Address - Fax:
Practice Address - Street 1:208 N 29TH ST
Practice Address - Street 2:SUITES 236-237
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-1985
Practice Address - Country:US
Practice Address - Phone:406-899-1008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0503308Medicaid
MT5485Medicare ID - Type Unspecified