Provider Demographics
NPI:1083985915
Name:BERGMAN, GLADYS (CHA P)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:CHA P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MAIN ROAD # 15
Mailing Address - Street 2:
Mailing Address - City:ALLAKAKET
Mailing Address - State:AK
Mailing Address - Zip Code:99720
Mailing Address - Country:US
Mailing Address - Phone:907-968-2248
Mailing Address - Fax:
Practice Address - Street 1:MAIN ROAD # 15
Practice Address - Street 2:
Practice Address - City:ALLAKAKET
Practice Address - State:AK
Practice Address - Zip Code:99720
Practice Address - Country:US
Practice Address - Phone:907-968-2248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK99-328-P172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker