Provider Demographics
NPI:1912067877
Name:BERGSTROM, BARBARA JOY (OTR)
Entity Type:Individual
Prefix:MRS
First Name:BARBARA
Middle Name:JOY
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 W SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-2728
Mailing Address - Country:US
Mailing Address - Phone:218-624-4828
Mailing Address - Fax:218-624-4479
Practice Address - Street 1:4505 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2728
Practice Address - Country:US
Practice Address - Phone:218-624-4828
Practice Address - Fax:218-624-4479
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104652174400000X
WI211326174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist