Provider Demographics
NPI:1710223615
Name:BERGEN, JULIE SUSANNE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:SUSANNE
Last Name:BERGEN
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 1:311 CENTRE CT
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502-6512
Mailing Address - Country:US
Mailing Address - Phone:303-378-8735
Mailing Address - Fax:
Practice Address - Street 1:311 CENTRE CT
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94502-6512
Practice Address - Country:US
Practice Address - Phone:303-378-8735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15596225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist