Healthcare Provider Details

I. General information

NPI: 1861830978
Provider Name (Legal Business Name): KELLI MICHELLE BERG DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W MAIN ST
TISHOMINGO OK
73460-1724
US

IV. Provider business mailing address

2412 W KOOTENAI ST
BOISE ID
83705-5950
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-2334
  • Fax:
Mailing address:
  • Phone: 785-567-6049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-3305
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60221
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-3989
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11-04639
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: