Provider Demographics
NPI:1598068231
Name:BERGHEGER, KELLY DORSANNE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DORSANNE
Last Name:BERGHEGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:DORSANNE
Other - Last Name:PRETTYMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5013 147TH ST W
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6918
Mailing Address - Country:US
Mailing Address - Phone:651-442-3622
Mailing Address - Fax:
Practice Address - Street 1:7373 147TH ST W
Practice Address - Street 2:SUITE 108
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7690
Practice Address - Country:US
Practice Address - Phone:651-442-3622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-20
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist