Provider Demographics
NPI:1487256038
Name:BERGUM, JOSEPH PAUL (OTR)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:PAUL
Last Name:BERGUM
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26900 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-5312
Mailing Address - Country:US
Mailing Address - Phone:248-350-8070
Mailing Address - Fax:248-350-8078
Practice Address - Street 1:26900 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-5312
Practice Address - Country:US
Practice Address - Phone:248-350-8070
Practice Address - Fax:248-350-8078
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003453225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist