Provider Demographics
NPI:1477037331
Name:BERGMAN, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:BERGMAN
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 1:565 S LAWLER AVE
Mailing Address - Street 2:
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-9165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1455 N BAKER AVE
Practice Address - Street 2:
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-4336
Practice Address - Country:US
Practice Address - Phone:509-884-1497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60236326235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist