Provider Demographics
NPI:1780924183
Name:BERGVALL, BRETT (LPC)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:BERGVALL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:WALLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77485-0517
Mailing Address - Country:US
Mailing Address - Phone:979-451-3809
Mailing Address - Fax:979-217-1607
Practice Address - Street 1:7146 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:WALLIS
Practice Address - State:TX
Practice Address - Zip Code:77485-9507
Practice Address - Country:US
Practice Address - Phone:979-217-1581
Practice Address - Fax:979-217-1607
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67988101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional