Provider Demographics
NPI:1073523536
Name:BERG, PHYLLIS ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:ANN
Last Name:BERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 FOREST AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3792
Mailing Address - Country:US
Mailing Address - Phone:804-285-4121
Mailing Address - Fax:804-285-4123
Practice Address - Street 1:7301 FOREST AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3792
Practice Address - Country:US
Practice Address - Phone:804-285-4121
Practice Address - Fax:804-285-4123
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA77-1466-1Medicaid
VAR68331Medicare UPIN