Provider Demographics
NPI:1144993353
Name:BERG, TYLER KENNETH (PT, DPT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:KENNETH
Last Name:BERG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:WINTERS
Mailing Address - State:CA
Mailing Address - Zip Code:95694-1915
Mailing Address - Country:US
Mailing Address - Phone:530-574-4505
Mailing Address - Fax:
Practice Address - Street 1:81 CERNON ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-2803
Practice Address - Country:US
Practice Address - Phone:707-447-9750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64051225100000X
CA300350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist