Basic Information
| Provider Information | |||||||||
| NPI: | 1770716771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGNER | ||||||||
| FirstName: | RAE JEAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N 34TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548804477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153955380 | ||||||||
| FaxNumber: | 7153942682 | ||||||||
| Practice Location | |||||||||
| Address1: | 15954 RIVERS EDGE DR | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548437800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | 7153942682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2009 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 16202 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.