Provider Demographics
NPI:1083946909
Name:BERGER, GORDON MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:MARK
Last Name:BERGER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1626 WESTWOOD BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5621
Mailing Address - Country:US
Mailing Address - Phone:310-475-3376
Mailing Address - Fax:310-475-4704
Practice Address - Street 1:1626 WESTWOOD BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5621
Practice Address - Country:US
Practice Address - Phone:310-475-3376
Practice Address - Fax:310-475-4704
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARP40102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst