Basic Information
| Provider Information | |||||||||
| NPI: | 1104110600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGENDAHL | ||||||||
| FirstName: | KERRI | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.S.W., L.I.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 CHESTNUT ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137945700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 CAREW STREET | ||||||||
| Address2: | STE 2 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011042146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137949816 | ||||||||
| FaxNumber: | 4137944945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2011 | ||||||||
| LastUpdateDate: | 04/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 117748 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.