Provider Demographics
NPI:1124159074
Name:VANDE BERG, MICHELLE NICOLE (MS, AT,C, CSCS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:VANDE BERG
Suffix:
Gender:F
Credentials:MS, AT,C, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 CATHEDRAL LN
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19403-5151
Mailing Address - Country:US
Mailing Address - Phone:610-630-1284
Mailing Address - Fax:
Practice Address - Street 1:601 EAST MAIN ST.
Practice Address - Street 2:ESS ATHLETICS
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-1000
Practice Address - Country:US
Practice Address - Phone:610-409-3000
Practice Address - Fax:610-409-3776
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART002373A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer