Provider Demographics
NPI:1598071557
Name:BERG, KATHLEEN MARIE (DPT, MS, CSCS, FAFS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:BERG
Suffix:
Gender:F
Credentials:DPT, MS, CSCS, FAFS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3858 N GARDEN CENTER WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5008
Mailing Address - Country:US
Mailing Address - Phone:208-830-1668
Mailing Address - Fax:208-620-3968
Practice Address - Street 1:3858 N GARDEN CENTER WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703
Practice Address - Country:US
Practice Address - Phone:208-830-1668
Practice Address - Fax:208-620-3968
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
225100000X
IDPT2717225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist