Provider Demographics
NPI:1265565204
Name:BERGSTROM, AMY JANE (PT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JANE
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 BIRCH HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:BORDENTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08505-4260
Mailing Address - Country:US
Mailing Address - Phone:609-499-0371
Mailing Address - Fax:
Practice Address - Street 1:902 JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08016-3814
Practice Address - Country:US
Practice Address - Phone:609-239-3894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA00588200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist