Provider Demographics
NPI:1881824456
Name:BERG, MICHELLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:DICKSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:15530 W 64TH AVE UNIT E
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80007-6874
Practice Address - Country:US
Practice Address - Phone:303-424-4589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP026712T225100000X
UTCP028293T225100000X
OHCP021343T225100000X
ARCP028292T225100000X
DECP028294T225100000X
CA293599225100000X
COPTL.0016655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY186531Medicaid