Healthcare Provider Details

I. General information

NPI: 1508667510
Provider Name (Legal Business Name): MIRAYAH BERGMANN ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIA BERGMANN ATC, LAT

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 ACADEMY LN
NORTH BRIDGTON ME
04057-1808
US

IV. Provider business mailing address

11 ACADEMY LN
NORTH BRIDGTON ME
04057-1808
US

V. Phone/Fax

Practice location:
  • Phone: 207-691-5843
  • Fax: 207-810-2020
Mailing address:
  • Phone: 207-691-5843
  • Fax: 207-810-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT609
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: