Provider Demographics
NPI:1982481081
Name:BERG, KAMBRY ALISE (LMT)
Entity Type:Individual
Prefix:
First Name:KAMBRY
Middle Name:ALISE
Last Name:BERG
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 1:2515 NW 22ND ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-7654
Mailing Address - Country:US
Mailing Address - Phone:541-852-6770
Mailing Address - Fax:
Practice Address - Street 1:716 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2648
Practice Address - Country:US
Practice Address - Phone:541-852-6770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19393225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist