Provider Demographics
NPI:1427210103
Name:BERGSTROM, LYNNETTE MARIE (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:LYNNETTE
Middle Name:MARIE
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4243 THOUSAND OAKS DR
Mailing Address - Street 2:#158
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-1801
Mailing Address - Country:US
Mailing Address - Phone:210-951-1151
Mailing Address - Fax:
Practice Address - Street 1:4243 THOUSAND OAKS DR
Practice Address - Street 2:#158
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-1801
Practice Address - Country:US
Practice Address - Phone:210-951-1151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1063533225X00000X
TX116606225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist