Basic Information
| Provider Information | |||||||||
| NPI: | 1104332626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGER | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2685 S FOREST DALE CIR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841062245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014525505 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 344 E 100 S STE 301 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841111727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014284257 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2017 | ||||||||
| LastUpdateDate: | 12/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.