Provider Demographics
NPI:1881161057
Name:BERGESEN, BRADI
Entity type:Individual
Prefix:
First Name:BRADI
Middle Name:
Last Name:BERGESEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 TOWNE RD
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-8867
Mailing Address - Country:US
Mailing Address - Phone:360-209-7680
Mailing Address - Fax:360-326-1143
Practice Address - Street 1:1653 TOWNE RD
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-8867
Practice Address - Country:US
Practice Address - Phone:360-209-7680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW609238601041C0700X
WASC606257221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical