Provider Demographics
NPI:1922369172
Name:BERTO, MIRIAM (LMT)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:BERTO
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 1:510 WINGSPAN WAY
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2255
Mailing Address - Country:US
Mailing Address - Phone:850-238-2110
Mailing Address - Fax:
Practice Address - Street 1:1125 JOHN SIMS PKWY E
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2752
Practice Address - Country:US
Practice Address - Phone:850-238-2110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA62072225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist