Provider Demographics
NPI:1629603550
Name:BERGIN, LISA BETH
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:BETH
Last Name:BERGIN
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 1:1441 S LINDSAY RD APT 1042
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6288
Mailing Address - Country:US
Mailing Address - Phone:860-478-4533
Mailing Address - Fax:
Practice Address - Street 1:1441 S LINDSAY RD APT 1042
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6288
Practice Address - Country:US
Practice Address - Phone:860-478-4533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6495225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty