Healthcare Provider Details

I. General information

NPI: 1598696122
Provider Name (Legal Business Name): JULIE ANN BERGENSTOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 SOUTH ST
CRANSTON RI
02920-1750
US

IV. Provider business mailing address

48 SOUTH ST
CRANSTON RI
02920-1750
US

V. Phone/Fax

Practice location:
  • Phone: 401-492-4168
  • Fax:
Mailing address:
  • Phone: 401-492-4168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16387-MT-MT
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: