Provider Demographics
NPI:1346546629
Name:BERG, PATRICIA (LMT)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 HOOVER AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-2242
Mailing Address - Country:US
Mailing Address - Phone:701-471-9683
Mailing Address - Fax:
Practice Address - Street 1:425 S 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5801
Practice Address - Country:US
Practice Address - Phone:701-258-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND653225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist