MEDICARE: KRISTEN BERGMANN SLPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2355S0801X	Speech-Language Assistant	SPA1255	CA

General Provider Information

NPI Number	:	1497009872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN BERGMANN SLPA

Provider Business Mailing Address
First Line	:	31901 VIA COYOTE
Second Line	:
City	:	COTO DE CAZA
State	:	CA
Zip	:	92679-4110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	30252 TOMAS
Second Line	:
City	:	RANCHO SANTA MARGARITA
State	:	CA
Zip	:	92688-2129
Country	:	US
Telephone Number	:	949-459-1658
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2012
Last Update Date	:	11/06/2012

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