Provider Demographics
NPI:1447723010
Name:VAN BERGEN, LISA (LPC, LAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VAN BERGEN
Suffix:
Gender:F
Credentials:LPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 PAULINE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4030
Mailing Address - Country:US
Mailing Address - Phone:843-795-0238
Mailing Address - Fax:843-795-8290
Practice Address - Street 1:1242 PAULINE AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-4030
Practice Address - Country:US
Practice Address - Phone:843-795-0238
Practice Address - Fax:843-795-8290
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC520101YA0400X
SC2268101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2268OtherSTATE LICENSURE BOARD