Provider Demographics
NPI:1396309159
Name:BERGSTROM, LAURA KAY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KAY
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:KAY
Other - Last Name:GREENBLAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1333 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4626
Mailing Address - Country:US
Mailing Address - Phone:503-583-4497
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4628
Practice Address - Country:US
Practice Address - Phone:503-267-4096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11565235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR11565OtherSTATE SLP LICENSE