Provider Demographics
NPI:1467929299
Name:BERGLUND, KIMBERLY RAE (ACSW 123607)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAE
Last Name:BERGLUND
Suffix:
Gender:F
Credentials:ACSW 123607
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 S MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2902
Mailing Address - Country:US
Mailing Address - Phone:626-795-9127
Mailing Address - Fax:
Practice Address - Street 1:44 S MENTOR AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2902
Practice Address - Country:US
Practice Address - Phone:626-795-9127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA1237071041C0700X
CA83111101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health