Provider Demographics
NPI:1558565101
Name:BERGSTROM, NICOLE RENEE (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 CHAPEL BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:MD
Mailing Address - Zip Code:21830-1067
Mailing Address - Country:US
Mailing Address - Phone:443-260-0942
Mailing Address - Fax:
Practice Address - Street 1:2009 NORTHWOOD DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-7800
Practice Address - Country:US
Practice Address - Phone:410-603-5884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04523225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist