Provider Demographics
NPI:1043096241
Name:BERGENDAHL, ELIZABETH ANNE (MHA IP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:BERGENDAHL
Suffix:
Gender:F
Credentials:MHA IP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16047A HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-9753
Mailing Address - Country:US
Mailing Address - Phone:360-451-0267
Mailing Address - Fax:
Practice Address - Street 1:16047A HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-9753
Practice Address - Country:US
Practice Address - Phone:360-451-0267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist