Provider Demographics
NPI:1477935666
Name:DIXON, BERGDORF
Entity Type:Individual
Prefix:
First Name:BERGDORF
Middle Name:
Last Name:DIXON
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 1:2060 BELLS HWY
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-6815
Mailing Address - Country:US
Mailing Address - Phone:843-538-2055
Mailing Address - Fax:843-538-2058
Practice Address - Street 1:2060 BELLS HWY
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-6815
Practice Address - Country:US
Practice Address - Phone:843-538-2055
Practice Address - Fax:843-538-2058
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3219225200000X
SC8287225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist