Provider Demographics
NPI:1568940211
Name:BERGH, FREDERICK DOUGLAS I (LPC, LAT)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:DOUGLAS
Last Name:BERGH
Suffix:I
Gender:M
Credentials:LPC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 ANTLER DR STE 213
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-1726
Mailing Address - Country:US
Mailing Address - Phone:720-484-1961
Mailing Address - Fax:
Practice Address - Street 1:701 ANTLER DR STE 213
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1726
Practice Address - Country:US
Practice Address - Phone:720-484-1961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT-404101YA0400X
WYLPC-2038101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health