Provider Demographics
NPI:1285604330
Name:BERGEN, AUDREY R (OTRL)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:R
Last Name:BERGEN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:R
Other - Last Name:HOEKSEMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6204 EAGLE EYE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5006 COPPER NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-268-7988
Practice Address - Fax:505-268-8021
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1662225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics