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General NPI Number Information
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NPI Number | 1861830978
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Entity Type | Individual
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Provider Name | KELLI MICHELLE BERG DPT
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Gender | Female
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Dates
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Enumeration Date | 06/11/2013
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Last Update Date | 05/27/2020
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Provider Practice Location Address
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Address Line | 101 W MAIN ST
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City | TISHOMINGO
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State | OK
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Zip | 73460-1724
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Country | US
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Telephone | 580-371-2334
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Fax |
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Provider Business Mailing Address
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Address Line | 2412 W KOOTENAI ST
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City | BOISE
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State | ID
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Zip | 83705-5950
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Country | US
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Telephone | 785-567-6049
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT-3305
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 60221
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT-3989
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License Number State | HI
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Taxonomy #5
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 11-04639
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License Number State | KS
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