=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265847958
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GWENDOLYN LOUISE BERGMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2014
-----------------------------------------------------
Last Update Date | 06/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 E BROADWAY ST LOT 49
-----------------------------------------------------
City | FORT RECOVERY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45846-9318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-953-1789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 EAST BROADWAY ST. LOT 49
-----------------------------------------------------
City | FORT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-953-1789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | OH3128822
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------