MEDICARE: MRS. DONNA J BERGERON MSH ORTL CHT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XH1200X	Hand Occupational Therapist	OT1707	FL

General Provider Information

NPI Number	:	1376508853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DONNA J BERGERON MSH ORTL CHT

Provider Business Mailing Address
First Line	:	4008 GASTER AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6696
Country	:	US
Telephone Number	:	702-704-4440
Fax Number	:

Provider Business Practice Location Address
First Line	:	4008 GASTER AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6696
Country	:	US
Telephone Number	:	702-704-4440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	06/21/2013

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