Provider Demographics
NPI:1417945205
Name:BERGER, NICOLE R (MSPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:BERGER
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 BENTON DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-1256
Mailing Address - Country:US
Mailing Address - Phone:423-227-0386
Mailing Address - Fax:
Practice Address - Street 1:600 N HOLTZCLAW AVE
Practice Address - Street 2:STE 100
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1242
Practice Address - Country:US
Practice Address - Phone:423-622-0500
Practice Address - Fax:423-622-0564
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT05322225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3659241Medicaid
TN3659241Medicare ID - Type Unspecified