Provider Demographics
NPI:1285843722
Name:BERGENDAHL, DEBORAH (COTA)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:
Last Name:BERGENDAHL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 CONCORD ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-2942
Mailing Address - Country:US
Mailing Address - Phone:860-289-2356
Mailing Address - Fax:
Practice Address - Street 1:60 WEST ST
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-3518
Practice Address - Country:US
Practice Address - Phone:860-529-2521
Practice Address - Fax:860-563-2640
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000974224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant