Provider Demographics
NPI:1861526758
Name:BERG, HEATHER LYNN (PT)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:LYNN
Last Name:BERG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 CANYON RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-6264
Mailing Address - Country:US
Mailing Address - Phone:802-879-9500
Mailing Address - Fax:
Practice Address - Street 1:3000 WILLISTON RD
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6082
Practice Address - Country:US
Practice Address - Phone:802-658-6092
Practice Address - Fax:802-863-9565
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0002889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006863Medicaid
VT000882002Medicare PIN