Provider Demographics
NPI:1851835979
Name:OLSEN-BERGMAN, TABITHA LYNN (LAC)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:LYNN
Last Name:OLSEN-BERGMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 30TH AVE S
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5195
Mailing Address - Country:US
Mailing Address - Phone:218-422-5920
Mailing Address - Fax:
Practice Address - Street 1:1506 30TH AVE S
Practice Address - Street 2:SUITE A
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5195
Practice Address - Country:US
Practice Address - Phone:218-422-5920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1825171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1825OtherMINNESOTA STATE LICENSE NUMBER