Provider Demographics
NPI:1285063115
Name:BERGSTEDT, BRIAN (BS, LADC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BERGSTEDT
Suffix:
Gender:M
Credentials:BS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 WEST SUPERIOR STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802
Mailing Address - Country:US
Mailing Address - Phone:218-722-4379
Mailing Address - Fax:218-722-4333
Practice Address - Street 1:332 WEST SUPERIOR STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802
Practice Address - Country:US
Practice Address - Phone:218-722-4379
Practice Address - Fax:218-722-4333
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303201101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)