Provider Demographics
NPI:1679615769
Name:BERGUM, HARLAN (NBCHWC)
Entity type:Individual
Prefix:
First Name:HARLAN
Middle Name:
Last Name:BERGUM
Suffix:
Gender:M
Credentials:NBCHWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S RUSK AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-2019
Mailing Address - Country:US
Mailing Address - Phone:815-900-1580
Mailing Address - Fax:
Practice Address - Street 1:500 E VETERANS ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3105
Practice Address - Country:US
Practice Address - Phone:608-372-3971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 174H00000X
A-3273815171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679615769Medicaid