Provider Demographics
NPI:1689945289
Name:BERGER, KAITLIN WILLOUGHBY (LMT)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:WILLOUGHBY
Last Name:BERGER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 NE WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3807
Mailing Address - Country:US
Mailing Address - Phone:786-473-3854
Mailing Address - Fax:
Practice Address - Street 1:118 N KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2435
Practice Address - Country:US
Practice Address - Phone:503-288-4454
Practice Address - Fax:503-288-1783
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT# 18506111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR18506OtherLMT