Provider Demographics
NPI:1780411801
Name:BERGMANN, GUDJON (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:GUDJON
Middle Name:
Last Name:BERGMANN
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 HOGAN
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5402
Mailing Address - Country:US
Mailing Address - Phone:512-241-9638
Mailing Address - Fax:
Practice Address - Street 1:324 RIVERWALK DR STE 308
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-6936
Practice Address - Country:US
Practice Address - Phone:737-248-1499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-14
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT140730225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty