Provider Demographics
NPI:1811370851
Name:BERGEN, INGRID ROSE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:INGRID
Middle Name:ROSE
Last Name:BERGEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 W WHEAT RD
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-1973
Mailing Address - Country:US
Mailing Address - Phone:856-692-6673
Mailing Address - Fax:
Practice Address - Street 1:635 W WHEAT RD
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-1973
Practice Address - Country:US
Practice Address - Phone:856-692-6673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09024500224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant