Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 5452 | AZ |
N | 2251P0200X | Physical Therapist - Pediatrics | 5452 | AZ |
NPI | 1083776298 |
---|---|
Provider Name | Wendy Bergman |
First Address | Mesa, AZ 85206-2148 |
Second Address | Mesa, AZ 85206-2148 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
965600 | (05) | AZ |