Healthcare Provider Details

I. General information

NPI: 1235522590
Provider Name (Legal Business Name): MARJORIE BERGISTE-RAPHAEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARJORIE BERGISTE

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6169 S JOG RD STE A11
LAKE WORTH FL
33467-6586
US

IV. Provider business mailing address

6114 NEWPORT VILLAGE WAY
LAKE WORTH FL
33463-7330
US

V. Phone/Fax

Practice location:
  • Phone: 561-432-0111
  • Fax:
Mailing address:
  • Phone: 407-247-6114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number30063
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: