Provider Demographics
NPI:1942789425
Name:BERGMAN, TYLEA
Entity Type:Individual
Prefix:
First Name:TYLEA
Middle Name:
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 1:21698 PIEDMONT MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SD
Mailing Address - Zip Code:57769-7114
Mailing Address - Country:US
Mailing Address - Phone:605-390-4326
Mailing Address - Fax:
Practice Address - Street 1:21698 PIEDMONT MEADOWS RD
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SD
Practice Address - Zip Code:57769-7114
Practice Address - Country:US
Practice Address - Phone:605-390-4326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2199225100000X
SD2234225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist