Provider Demographics
NPI:1952064743
Name:BERGQUIST, ERICKA LYNN (AMFT, CTP)
Entity type:Individual
Prefix:
First Name:ERICKA
Middle Name:LYNN
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:AMFT, CTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 W STATE STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134
Mailing Address - Country:US
Mailing Address - Phone:630-428-7890
Mailing Address - Fax:
Practice Address - Street 1:28 W STATE STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134
Practice Address - Country:US
Practice Address - Phone:630-428-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208.000858106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist