Provider Demographics
NPI:1194214981
Name:BERGAN, HEATHER CARR (PTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:CARR
Last Name:BERGAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9608 CROSS RD
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-9592
Mailing Address - Country:US
Mailing Address - Phone:240-383-7371
Mailing Address - Fax:
Practice Address - Street 1:ROLAND PARK PLACE REHAB DEPT.
Practice Address - Street 2:830 W 40TH ST
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211
Practice Address - Country:US
Practice Address - Phone:410-243-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2276225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant