Provider Demographics
NPI:1285702233
Name:BERGLUND, MARISA ELAINE (LMP)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:ELAINE
Last Name:BERGLUND
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N 149TH ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-6411
Mailing Address - Country:US
Mailing Address - Phone:206-850-3858
Mailing Address - Fax:425-778-2604
Practice Address - Street 1:51 W DAYTON ST
Practice Address - Street 2:SUITE 304
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-4111
Practice Address - Country:US
Practice Address - Phone:425-582-0884
Practice Address - Fax:425-778-2604
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016829174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0161538OtherLABOR AND INDUSTRIES
WA602223683Medicare UPIN