Provider Demographics
NPI:1912538000
Name:BERGMAN, STACY HEATHER
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:HEATHER
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-6702
Mailing Address - Country:US
Mailing Address - Phone:580-340-3728
Mailing Address - Fax:
Practice Address - Street 1:1601 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-4409
Practice Address - Country:US
Practice Address - Phone:580-340-3728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOA780224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant