Provider Demographics
NPI:1922308964
Name:BERG, KEVIN (PTA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BERG
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 WOODBURY CMN
Mailing Address - Street 2:UNIT D
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-7780
Mailing Address - Country:US
Mailing Address - Phone:262-542-8949
Mailing Address - Fax:
Practice Address - Street 1:1210 WOODBURY CMN
Practice Address - Street 2:UNIT D
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-7780
Practice Address - Country:US
Practice Address - Phone:262-542-8949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI285-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100013086Medicaid