Provider Demographics
NPI:1245582535
Name:BERGEN, BRUCE THOMAS (PTA)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:THOMAS
Last Name:BERGEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34921 US HIGHWAY 19 N
Mailing Address - Street 2:SUITE 450
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-1969
Mailing Address - Country:US
Mailing Address - Phone:800-251-8998
Mailing Address - Fax:727-573-2648
Practice Address - Street 1:34921 US HIGHWAY 19 N
Practice Address - Street 2:SUITE 450
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1969
Practice Address - Country:US
Practice Address - Phone:800-251-8998
Practice Address - Fax:727-573-2648
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 15613225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant