Provider Demographics
NPI:1306161120
Name:BERGEN, ANNA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:BERGEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:CULLOWHEE
Mailing Address - State:NC
Mailing Address - Zip Code:28723-0432
Mailing Address - Country:US
Mailing Address - Phone:828-586-1612
Mailing Address - Fax:828-586-0420
Practice Address - Street 1:919 HAYWOOD RD, STE 101
Practice Address - Street 2:
Practice Address - City:DILLSBORO
Practice Address - State:NC
Practice Address - Zip Code:28725-0000
Practice Address - Country:US
Practice Address - Phone:828-586-1612
Practice Address - Fax:828-586-0420
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8414235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14006348OtherASHA
NC8414OtherNC STATE LICENSURE