Provider Demographics
NPI:1033553060
Name:BERGIN, NICHOLE MARIE (LMT)
Entity Type:Individual
Prefix:MISS
First Name:NICHOLE
Middle Name:MARIE
Last Name:BERGIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BROOKHILL DR
Mailing Address - Street 2:
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994-2101
Mailing Address - Country:US
Mailing Address - Phone:845-480-4432
Mailing Address - Fax:
Practice Address - Street 1:175 ROUTE 304
Practice Address - Street 2:
Practice Address - City:BARDONIA
Practice Address - State:NY
Practice Address - Zip Code:10954-2042
Practice Address - Country:US
Practice Address - Phone:845-507-0477
Practice Address - Fax:845-507-0490
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-21
Last Update Date:2013-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025947225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist