Provider Demographics
NPI:1659346179
Name:BERGER, KATHLEEN ANN (PT)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANN
Last Name:BERGER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1146
Mailing Address - Street 2:
Mailing Address - City:CLARKDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:86324-1146
Mailing Address - Country:US
Mailing Address - Phone:850-445-4821
Mailing Address - Fax:850-386-2765
Practice Address - Street 1:26 N 10TH ST.
Practice Address - Street 2:
Practice Address - City:CLARKDALE
Practice Address - State:AZ
Practice Address - Zip Code:86324-1146
Practice Address - Country:US
Practice Address - Phone:850-445-4821
Practice Address - Fax:850-386-2765
Is Sole Proprietor?:No
Enumeration Date:2006-02-19
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-30124225100000X
FLPT 16091225100000X
FLPT16091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888125100Medicaid
FL678168396Medicaid