Provider Demographics
NPI:1962978700
Name:BERDIN, LUKE DEREK CASONA (PT, DPT)
Entity type:Individual
Prefix:
First Name:LUKE DEREK
Middle Name:CASONA
Last Name:BERDIN
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 1:1336 STONE RIDGE RD APT 57
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-8639
Mailing Address - Country:US
Mailing Address - Phone:929-273-9321
Mailing Address - Fax:
Practice Address - Street 1:717 E ALFRED ST, WEYAUWEGA, WI 54983
Practice Address - Street 2:
Practice Address - City:WEYAUWEGA
Practice Address - State:WI
Practice Address - Zip Code:54983
Practice Address - Country:US
Practice Address - Phone:920-867-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14132-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist