Provider Demographics
NPI:1851906697
Name:BERG, TADD WILLIAM
Entity Type:Individual
Prefix:
First Name:TADD
Middle Name:WILLIAM
Last Name:BERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 14TH ST BLDG 1830
Mailing Address - Street 2:
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-5302
Mailing Address - Country:US
Mailing Address - Phone:337-718-2913
Mailing Address - Fax:
Practice Address - Street 1:2030 14TH ST BLDG 1830
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5302
Practice Address - Country:US
Practice Address - Phone:337-718-2913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1150812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer