Provider Demographics
NPI:1861830978
Name:BERG, KELLI MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MICHELLE
Last Name:BERG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 W KOOTENAI ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-5950
Mailing Address - Country:US
Mailing Address - Phone:785-567-6049
Mailing Address - Fax:
Practice Address - Street 1:101 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-1724
Practice Address - Country:US
Practice Address - Phone:580-371-2334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3305225100000X
OR60221225100000X
390200000X
HIPT-3989225100000X
KS11-04639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program