Provider Demographics
NPI:1174320055
Name:BERGSTROM, KAYLA C (PCSW)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:C
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:PCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 GRAY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WY
Mailing Address - Zip Code:82701-3130
Mailing Address - Country:US
Mailing Address - Phone:307-746-8787
Mailing Address - Fax:
Practice Address - Street 1:1708 GRAY BLVD
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WY
Practice Address - Zip Code:82701-3130
Practice Address - Country:US
Practice Address - Phone:307-746-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPCSW-12061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty