Provider Demographics
NPI:1770716771
Name:BERGNER, RAE JEAN (CSAC)
Entity type:Individual
Prefix:
First Name:RAE JEAN
Middle Name:
Last Name:BERGNER
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N 34TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-4477
Mailing Address - Country:US
Mailing Address - Phone:715-395-5380
Mailing Address - Fax:715-394-2682
Practice Address - Street 1:15954 RIVERS EDGE DR
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-7800
Practice Address - Country:US
Practice Address - Phone:715-634-2541
Practice Address - Fax:715-394-2682
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16202101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)