Provider Demographics
NPI:1063454114
Name:BERG, CARL STACEY (MASTER OF SCIENCE MS)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:STACEY
Last Name:BERG
Suffix:
Gender:M
Credentials:MASTER OF SCIENCE MS
Other - Prefix:MR
Other - First Name:CARL
Other - Middle Name:JEFFREY
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AUD
Mailing Address - Street 1:1867 WILLIAMS HWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5854
Mailing Address - Country:US
Mailing Address - Phone:541-474-4694
Mailing Address - Fax:541-474-9590
Practice Address - Street 1:1867 WILLIAMS HWY
Practice Address - Street 2:SUITE 105
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5854
Practice Address - Country:US
Practice Address - Phone:541-474-4694
Practice Address - Fax:541-474-9590
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20545231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR283606Medicaid
OR0000VGBFQMedicare UPIN