Provider Demographics
NPI:1700484409
Name:BERGLUND, TINA MARIE (PRSS)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:BERGLUND
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 SHEPPARD ST
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-4838
Mailing Address - Country:US
Mailing Address - Phone:503-753-4956
Mailing Address - Fax:
Practice Address - Street 1:7217 N COUNTY LINE ROAD
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:OK
Practice Address - Zip Code:73078
Practice Address - Country:US
Practice Address - Phone:174-940-5878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
THW000001848175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist