Provider Demographics
NPI:1912382946
Name:BERGDALL, GINA (COTA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BERGDALL
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 1:18 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:PAWLING
Mailing Address - State:NY
Mailing Address - Zip Code:12564-1031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 GLEN HILL RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811-4921
Practice Address - Country:US
Practice Address - Phone:203-744-2840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1602224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant