Provider Demographics
NPI:1124388475
Name:BERGSBAKEN, AMY JANICE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JANICE
Last Name:BERGSBAKEN
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 1:300 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5643
Mailing Address - Country:US
Mailing Address - Phone:763-767-0854
Mailing Address - Fax:763-862-6533
Practice Address - Street 1:300 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 200
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5643
Practice Address - Country:US
Practice Address - Phone:763-767-0854
Practice Address - Fax:763-862-6533
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8920235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist