MEDICARE: SUSAN RUTH BERG OTR

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	225X00000X	Occupational Therapist	118851	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	118851	OTHER	TX	EPTOTE

General Provider Information

NPI Number	:	1871001149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN RUTH BERG OTR

Provider Business Mailing Address
First Line	:	3223 LEMMON AVE APT 4129
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-1855
Country	:	US
Telephone Number	:	951-760-6070
Fax Number	:

Provider Business Practice Location Address
First Line	:	3223 LEMMON AVE APT 4129
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-1855
Country	:	US
Telephone Number	:	951-760-6070
Fax Number	:

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

Provider Enumeration Date	:	01/19/2018
Last Update Date	:	06/16/2018

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Directions to “ SUSAN RUTH BERG OTR” Practice Location

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