Provider Demographics
NPI:1194821157
Name:BERG, AMBER (OTR/L)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E 1ST ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2297
Mailing Address - Country:US
Mailing Address - Phone:218-625-1884
Mailing Address - Fax:218-722-6515
Practice Address - Street 1:1000 E 1ST ST
Practice Address - Street 2:SUITE 404
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2297
Practice Address - Country:US
Practice Address - Phone:218-625-1884
Practice Address - Fax:218-722-6515
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102903225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN941498300Medicaid
MN106G2BEOtherBCBS MN INDIVIDUAL
MN6404781OtherMN MEDICA INDIVIDUAL
WI40882400Medicaid
MN941498300Medicaid