Provider Demographics
NPI:1366852071
Name:BERG, BROOKLYNN
Entity Type:Individual
Prefix:
First Name:BROOKLYNN
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 YELLOWSTONE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-1834
Mailing Address - Country:US
Mailing Address - Phone:406-245-9330
Mailing Address - Fax:
Practice Address - Street 1:1415 YELLOWSTONE RIVER RD
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-1834
Practice Address - Country:US
Practice Address - Phone:406-245-9330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PTA-LIC-6017225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant