Provider Demographics
NPI:1720705734
Name:BERG, EMILY (ATC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12110 CREEKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-9531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 N CAMPUS
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14853-6007
Practice Address - Country:US
Practice Address - Phone:607-255-4237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20000524162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer