Provider Demographics
NPI:1790465490
Name:BERGAMASCO, KATHERINE COLLETTE (CLVT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:COLLETTE
Last Name:BERGAMASCO
Suffix:
Gender:F
Credentials:CLVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:949 S GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-3210
Mailing Address - Country:US
Mailing Address - Phone:316-239-2736
Mailing Address - Fax:316-239-2747
Practice Address - Street 1:949 S GLENDALE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-3210
Practice Address - Country:US
Practice Address - Phone:316-239-2736
Practice Address - Fax:316-239-2747
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
216572255R0406X, 225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255R0406XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistRehabilitation, Blind
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor