Provider Demographics
NPI:1417296237
Name:BERGH, KIM (PTA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BERGH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E8625 595TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELK MOUND
Mailing Address - State:WI
Mailing Address - Zip Code:54739-9037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CORNELL
Practice Address - State:WI
Practice Address - Zip Code:54732-8120
Practice Address - Country:US
Practice Address - Phone:715-239-0440
Practice Address - Fax:715-239-6608
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1724-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant