Provider Demographics
NPI:1336381524
Name:BERGAM, MATTHEW JOSEPH (MPT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:BERGAM
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12920 E 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-0296
Mailing Address - Country:US
Mailing Address - Phone:509-927-2875
Mailing Address - Fax:
Practice Address - Street 1:1224 E WESTVIEW CT
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-3813
Practice Address - Country:US
Practice Address - Phone:509-467-5626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist