Provider Demographics
NPI:1033711551
Name:BERGMAN, ATHARA
Entity Type:Individual
Prefix:
First Name:ATHARA
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 W GRANFIELD AVE # 1/2
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-4845
Mailing Address - Country:US
Mailing Address - Phone:813-735-8052
Mailing Address - Fax:
Practice Address - Street 1:1301 S PARSONS AVE
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-4529
Practice Address - Country:US
Practice Address - Phone:813-693-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician