Provider Demographics
NPI:1750377511
Name:BERNA, KELLY LYNN (PTA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:BERNA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:KUCKSDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:116 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2356
Mailing Address - Country:US
Mailing Address - Phone:715-526-7370
Mailing Address - Fax:715-526-7294
Practice Address - Street 1:116 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2356
Practice Address - Country:US
Practice Address - Phone:715-526-7370
Practice Address - Fax:715-526-7294
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40390300Medicaid