Provider Demographics
NPI:1104208537
Name:BERGHOUT, ROSEMARIE
Entity Type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:
Last Name:BERGHOUT
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 1:2049 PERKERSON RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-5052
Mailing Address - Country:US
Mailing Address - Phone:404-549-9327
Mailing Address - Fax:404-963-5017
Practice Address - Street 1:2049 PERKERSON RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-5052
Practice Address - Country:US
Practice Address - Phone:404-549-9327
Practice Address - Fax:404-963-5017
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172V0000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker