Basic Information
Provider Information
NPI: 1033556758
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BERG
FirstName: MICHAEL
MiddleName: D.
NamePrefix:  
NameSuffix:  
Credential: MS, PLPC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 402 S SILVER SPRINGS RD
Address2:  
City: CAPE GIRARDEAU
State: MO
PostalCode: 637037536
CountryCode: US
TelephoneNumber: 5733341100
FaxNumber: 5736514345
Practice Location
Address1: 402 S SILVER SPRINGS RD
Address2:  
City: CAPE GIRARDEAU
State: MO
PostalCode: 637037536
CountryCode: US
TelephoneNumber: 5733341100
FaxNumber: 5736514345
Other Information
ProviderEnumerationDate: 06/04/2013
LastUpdateDate: 06/04/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X2011013938MOY Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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