Healthcare Provider Details

I. General information

NPI: 1265565204
Provider Name (Legal Business Name): AMY JANE BERGSTROM PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 JACKSONVILLE RD
BURLINGTON TOWNSHIP NJ
08016-3814
US

IV. Provider business mailing address

267 BIRCH HOLLOW DR
BORDENTOWN NJ
08505-4260
US

V. Phone/Fax

Practice location:
  • Phone: 609-239-3894
  • Fax:
Mailing address:
  • Phone: 609-499-0371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberQA00588200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: