MEDICARE: LISA BETH BERGIN

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	225XP0200X	Pediatric Occupational Therapist	6495	AZ

General Provider Information

NPI Number	:	1629603550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA BETH BERGIN

Provider Business Mailing Address
First Line	:	1441 S LINDSAY RD APT 1042
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204-6288
Country	:	US
Telephone Number	:	860-478-4533
Fax Number	:

Provider Business Practice Location Address
First Line	:	1441 S LINDSAY RD APT 1042
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204-6288
Country	:	US
Telephone Number	:	860-478-4533
Fax Number	:

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

Provider Enumeration Date	:	03/11/2020
Last Update Date	:	03/11/2020

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