Provider Demographics
NPI:1689121824
Name:BERGMAN, OLIVIA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2927 S FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6498
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2927 S FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-6498
Practice Address - Country:US
Practice Address - Phone:608-819-6394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4361-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist