Provider Demographics
NPI:1831910884
Name:BERGQUIST, OMIE (R15730824)
Entity type:Individual
Prefix:
First Name:OMIE
Middle Name:
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:R15730824
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 LAKEVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-6056
Mailing Address - Country:US
Mailing Address - Phone:760-668-9399
Mailing Address - Fax:
Practice Address - Street 1:69730 HIGHWAY 111 STE 109
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2873
Practice Address - Country:US
Practice Address - Phone:760-322-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1573930824101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)