Provider Demographics
NPI:1245350537
Name:BERGGREN, FREDERICK WILLIAM JR (PTA, ATC)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:BERGGREN
Suffix:JR
Gender:M
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:21 RIDGE RD
Mailing Address - Street 2:PO BOX 3457
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-8928
Mailing Address - Country:US
Mailing Address - Phone:860-536-8675
Mailing Address - Fax:
Practice Address - Street 1:495 GOLD STAR HWY
Practice Address - Street 2:SUITE112
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6228
Practice Address - Country:US
Practice Address - Phone:860-446-8254
Practice Address - Fax:860-446-8293
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0003932255A2300X
CT1133225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer