Provider Demographics
NPI:1124014451
Name:BERG, BRENDA R (LCSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:R
Last Name:BERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5282 W 250 S
Mailing Address - Street 2:
Mailing Address - City:RUSSIAVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46979-9412
Mailing Address - Country:US
Mailing Address - Phone:765-883-7873
Mailing Address - Fax:765-883-7714
Practice Address - Street 1:5282 W 250 S
Practice Address - Street 2:
Practice Address - City:RUSSIAVILLE
Practice Address - State:IN
Practice Address - Zip Code:46979-9412
Practice Address - Country:US
Practice Address - Phone:765-883-7873
Practice Address - Fax:765-883-7714
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YM0800X, 106H00000X
IN34004853A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000390310OtherANTHEM
IN000000390310OtherANTHEM