Provider Demographics
NPI:1073882403
Name:BERGMAN, RANDI
Entity Type:Individual
Prefix:MS
First Name:RANDI
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 1:33 ASH ST
Mailing Address - Street 2:SCHOOL 12 RELATED SERVICES
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14204-1445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 ASH ST
Practice Address - Street 2:SCHOOL 12 RELATED SERVICES
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14204-1445
Practice Address - Country:US
Practice Address - Phone:716-816-4748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002784-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist