Provider Demographics
NPI:1447138839
Name:BERGSTROM, ERIC ANDREW
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:ANDREW
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12490 W FIELDING CIR
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-3022
Mailing Address - Country:US
Mailing Address - Phone:424-447-5797
Mailing Address - Fax:
Practice Address - Street 1:12490 W FIELDING CIR
Practice Address - Street 2:
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-3022
Practice Address - Country:US
Practice Address - Phone:424-447-5797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA522036225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist