Healthcare Provider Details

I. General information

NPI: 1053835173
Provider Name (Legal Business Name): KIM M BERG OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM M KELSEY OTR/L

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S BROADWAY
GREEN BAY WI
54303-1516
US

IV. Provider business mailing address

701 WILLOW STREET
PESHTIGO WI
54174
US

V. Phone/Fax

Practice location:
  • Phone: 920-228-9065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3018-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: