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General NPI Number Information
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NPI Number | 1558565101
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Entity Type | Individual
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Provider Name | NICOLE RENEE BERGSTROM OTR
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Gender | Female
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Dates
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Enumeration Date | 06/14/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2009 NORTHWOOD DR
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City | SALISBURY
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State | MD
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Zip | 21801-7800
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Country | US
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Telephone | 410-603-5884
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Fax |
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Provider Business Mailing Address
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Address Line | 169 CHAPEL BRANCH DR
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City | HEBRON
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State | MD
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Zip | 21830-1067
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Country | US
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Telephone | 443-260-0942
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 04523
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License Number State | MD
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