1558423400 NPI number — MS. MILIA BETH BERGKOETTER MS MFCC LCPC

Table of content: MS. MILIA BETH BERGKOETTER MS MFCC LCPC (NPI 1558423400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558423400 NPI number — MS. MILIA BETH BERGKOETTER MS MFCC LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGKOETTER
Provider First Name:
MILIA
Provider Middle Name:
BETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS MFCC LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HANCE HOSSEINI
Provider Other First Name:
MILIA
Provider Other Middle Name:
BETH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS MFCC LCPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558423400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8802 S 700 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSPORT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47993
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-793-7318
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1022 N VERMILION
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-446-4747
Provider Business Practice Location Address Fax Number:
217-446-1734
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09227965 . This is a "BC BS" identifier . This identifiers is of the category "OTHER".




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