Provider Demographics
NPI:1083776298
Name:BERGMAN, WENDY (PT)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 S HIGLEY RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2148
Mailing Address - Country:US
Mailing Address - Phone:480-892-9777
Mailing Address - Fax:480-635-0222
Practice Address - Street 1:551 S HIGLEY RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2148
Practice Address - Country:US
Practice Address - Phone:480-892-9777
Practice Address - Fax:480-635-0222
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5452225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ965600Medicaid