Provider Demographics
NPI:1669334520
Name:BERGEN, ZOE
Entity type:Individual
Prefix:
First Name:ZOE
Middle Name:
Last Name:BERGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10860 GILBERT RD
Mailing Address - Street 2:
Mailing Address - City:RILEY
Mailing Address - State:MI
Mailing Address - Zip Code:48041-3928
Mailing Address - Country:US
Mailing Address - Phone:810-543-7605
Mailing Address - Fax:810-543-7605
Practice Address - Street 1:10860 GILBERT RD
Practice Address - Street 2:
Practice Address - City:RILEY
Practice Address - State:MI
Practice Address - Zip Code:48041-3928
Practice Address - Country:US
Practice Address - Phone:810-543-7605
Practice Address - Fax:810-543-7605
Is Sole Proprietor?:No
Enumeration Date:2025-12-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer