Provider Demographics
NPI:1316342801
Name:BERGMAN, SAMANTHA (MS, AT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:MS, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4174 PORTER RD
Mailing Address - Street 2:
Mailing Address - City:ROOTSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44272-9576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4174 PORTER RD
Practice Address - Street 2:
Practice Address - City:ROOTSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44272-9576
Practice Address - Country:US
Practice Address - Phone:330-571-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0050252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer