Provider Demographics
NPI:1750933685
Name:BERGH, KRISTYN FAITH
Entity type:Individual
Prefix:
First Name:KRISTYN
Middle Name:FAITH
Last Name:BERGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3835 SUPREME CT NW STE 2
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-4485
Mailing Address - Country:US
Mailing Address - Phone:218-444-8280
Mailing Address - Fax:
Practice Address - Street 1:118 CENTRAL STREET WEST
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621
Practice Address - Country:US
Practice Address - Phone:218-694-3030
Practice Address - Fax:218-694-3033
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist