Provider Demographics
NPI:1215458138
Name:JULIE BERGAN COUNSELING LLC
Entity type:Organization
Organization Name:JULIE BERGAN COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BERGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:574-269-5829
Mailing Address - Street 1:412 AUDITORIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:WINONA LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46590-1064
Mailing Address - Country:US
Mailing Address - Phone:574-269-5829
Mailing Address - Fax:
Practice Address - Street 1:313 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3709
Practice Address - Country:US
Practice Address - Phone:574-535-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-30
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007808A261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)