Provider Demographics
NPI:1831462837
Name:BERGMAN, MOLLY ANN (DPT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11704 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5830
Mailing Address - Country:US
Mailing Address - Phone:405-692-5205
Mailing Address - Fax:405-692-5210
Practice Address - Street 1:11704 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-5830
Practice Address - Country:US
Practice Address - Phone:405-692-5205
Practice Address - Fax:405-692-5210
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4747225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist