1861526758 NPI number — MS. HEATHER LYNN BERG PT

Table of content: MS. HEATHER LYNN BERG PT (NPI 1861526758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861526758 NPI number — MS. HEATHER LYNN BERG PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERG
Provider First Name:
HEATHER
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861526758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
158 CANYON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLCHESTER
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05446-6264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-879-9500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 WILLISTON RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
SOUTH BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05403-6082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-658-6092
Provider Business Practice Location Address Fax Number:
802-863-9565
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  040-0002889 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1006863 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com