Provider Demographics
NPI:1750021234
Name:BERGDALL, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BERGDALL
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 1:104 BURR ST
Mailing Address - Street 2:
Mailing Address - City:MOOREFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:26836-1210
Mailing Address - Country:US
Mailing Address - Phone:304-257-6020
Mailing Address - Fax:
Practice Address - Street 1:7 MOUNTAIN VIEW ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1796
Practice Address - Country:US
Practice Address - Phone:130-425-7115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist