Provider Demographics
NPI:1538495320
Name:BERGESON, BRANDY (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:
Last Name:BERGESON
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 1:18107 N PALOMINO RD
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005-9316
Mailing Address - Country:US
Mailing Address - Phone:509-863-9291
Mailing Address - Fax:
Practice Address - Street 1:18107 N PALOMINO RD
Practice Address - Street 2:
Practice Address - City:COLBERT
Practice Address - State:WA
Practice Address - Zip Code:99005-9316
Practice Address - Country:US
Practice Address - Phone:509-863-9291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT 60100681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist