Provider Demographics
NPI:1558517862
Name:BERG, TINA LOUISE (LMP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LOUISE
Last Name:BERG
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 W MCGRAW ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98199-3236
Mailing Address - Country:US
Mailing Address - Phone:206-283-9860
Mailing Address - Fax:
Practice Address - Street 1:3203 W MCGRAW ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3236
Practice Address - Country:US
Practice Address - Phone:206-283-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015790225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist