Provider Demographics
NPI:1962642066
Name:BERG, MARLO (CMT)
Entity Type:Individual
Prefix:MISS
First Name:MARLO
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2935 FREMONT AVE S
Mailing Address - Street 2:#401
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2085
Mailing Address - Country:US
Mailing Address - Phone:612-382-6343
Mailing Address - Fax:
Practice Address - Street 1:2935 FREMONT AVE S
Practice Address - Street 2:#401
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2085
Practice Address - Country:US
Practice Address - Phone:612-382-6343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN208210225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist