Healthcare Provider Details

I. General information

NPI: 1154534360
Provider Name (Legal Business Name): LEAH BETH BERGMANN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

103 NORWAY ST #27
BOSTON MA
02115-3427
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1347
  • Fax:
Mailing address:
  • Phone: 617-851-8317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8064
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: