Provider Demographics
NPI:1932539244
Name:BRIMLEY-BERGSTROM, SHAUNA RENEE
Entity Type:Individual
Prefix:MRS
First Name:SHAUNA
Middle Name:RENEE
Last Name:BRIMLEY-BERGSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 POND ST.
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-945-4334
Mailing Address - Fax:
Practice Address - Street 1:37 POND ST.
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-945-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT2623225XP0200X
MA2503225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics