Provider Demographics
NPI:1245856004
Name:BERGSTRESSER, NICOLE LEANNE (MA, LADC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEANNE
Last Name:BERGSTRESSER
Suffix:
Gender:F
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5748 QUAIL AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2809
Mailing Address - Country:US
Mailing Address - Phone:763-439-8035
Mailing Address - Fax:
Practice Address - Street 1:5201 BRYANT AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-3588
Practice Address - Country:US
Practice Address - Phone:612-284-8115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305389101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)