Provider Demographics
NPI:1508985375
Name:BERG-POPPE, PATTI J (MA, MPT)
Entity Type:Individual
Prefix:MS
First Name:PATTI
Middle Name:J
Last Name:BERG-POPPE
Suffix:
Gender:F
Credentials:MA, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 S GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-0312
Mailing Address - Country:US
Mailing Address - Phone:605-338-2156
Mailing Address - Fax:
Practice Address - Street 1:2501 W 26TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-2446
Practice Address - Country:US
Practice Address - Phone:605-782-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1169225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5833940Medicaid