Individual
KELLI MICHELLE BERG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DPT
Contact information
Practice address
101 W MAIN ST, TISHOMINGO, OK 73460-1724
(580) 371-2334
Mailing address
2412 W KOOTENAI ST, BOISE, ID 83705-5950
(785) 567-6049
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
11-04639
KS
225100000X
Physical Therapist
60221
OR
225100000X
Physical Therapist
PT-3305
ID
225100000X
Physical Therapist
Primary
PT-3989
HI
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
06/11/2013
Last updated
05/27/2020
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