Provider Demographics
NPI:1508367814
Name:BERGESEN, ANNETTE
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:BERGESEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:WIKLUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:206 N 2100 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2472 S 300 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2895
Practice Address - Country:US
Practice Address - Phone:801-466-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9854061-4202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant