Provider Demographics
NPI:1073044558
Name:BERGEE, MARA NATALIE (DPT)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:NATALIE
Last Name:BERGEE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2944
Mailing Address - Country:US
Mailing Address - Phone:651-353-1406
Mailing Address - Fax:
Practice Address - Street 1:3821 S CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-3712
Practice Address - Country:US
Practice Address - Phone:414-762-7336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-25
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13585-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist