Provider Demographics
NPI:1306264098
Name:BERGQUIST, KERRI
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 SANTUIT POND RD
Mailing Address - Street 2:
Mailing Address - City:MASHPEE
Mailing Address - State:MA
Mailing Address - Zip Code:02649-2421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:470 MAIN ST
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-2047
Practice Address - Country:US
Practice Address - Phone:508-760-1475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAFUW653A24076OtherBLUE CROSS BLUE SHIELD