Provider Demographics
NPI:1285110247
Name:VANDER BERG, CODY (DPT)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:VANDER BERG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-7720
Mailing Address - Country:US
Mailing Address - Phone:712-578-9549
Mailing Address - Fax:
Practice Address - Street 1:8862 BENDER RD STE 101
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-8800
Practice Address - Country:US
Practice Address - Phone:360-354-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist