Healthcare Provider Details

I. General information

NPI: 1285604330
Provider Name (Legal Business Name): AUDREY R BERGEN OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AUDREY R HOEKSEMA

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5006 COPPER NE
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

6204 EAGLE EYE NW
ALBUQUERQUE NM
87120
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-7988
  • Fax: 505-268-8021
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1662
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: