Basic Information
| Provider Information | |||||||||
| NPI: | 1891207080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGSMA | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ORR | ||||||||
| OtherFirstName: | MARISSA | ||||||||
| OtherMiddleName: | LAUREN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2915 EARLE AVE SW | ||||||||
| Address2: | |||||||||
| City: | GRANDVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494181467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162603174 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2786 56TH ST SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494188708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162613960 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2017 | ||||||||
| LastUpdateDate: | 10/29/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7101004623 | MI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.