Doctor Name: | BRETT BERGVALL |
NPI Number: | 1780924183 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | LPC |
License Number: | 67988 |
Business Practice Address: | 7146 Highway 60 Wallis, TX - 774859507 |
Business Phone Number: | 9792171581 |
Business Fax Number: | 9792171607 |
Mailing Address: | Po Box 517, WALLIS |
State: | TX |
Postal Code: | 774850517 |
Phone Number: | 9794513809 |
Fax Number: | 9792171607 |
NPI Enumeration Date: | 02/21/2013 |
NPI Last Update Date: | 08/05/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YP2500X |
License Number: | 67988 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | TX |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Professional |
Taxonomy Definition: |