Provider Demographics
NPI:1225407349
Name:BERGGREN-MUSTARD, MORGAN
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:BERGGREN-MUSTARD
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 1:15720 E 4TH AVE APT G308
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-2105
Mailing Address - Country:US
Mailing Address - Phone:509-808-1995
Mailing Address - Fax:
Practice Address - Street 1:325 S SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-6019
Practice Address - Country:US
Practice Address - Phone:509-928-9098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60551415225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist