Provider Demographics
NPI:1679069595
Name:BERGLUND, KATHERINE MARIAH (MAT, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIAH
Last Name:BERGLUND
Suffix:
Gender:F
Credentials:MAT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7058
Mailing Address - Country:US
Mailing Address - Phone:208-352-2584
Mailing Address - Fax:
Practice Address - Street 1:3302 VALENCIA DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7058
Practice Address - Country:US
Practice Address - Phone:208-352-2584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
ND884-202255A2300X
IDAT-7762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer