Provider Demographics
NPI:1295382836
Name:BERG, LETICIA MELANIE (MA, MLP)
Entity Type:Individual
Prefix:MS
First Name:LETICIA
Middle Name:MELANIE
Last Name:BERG
Suffix:
Gender:F
Credentials:MA, MLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28475 GREENFIELD RD STE 113-1312
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3034
Mailing Address - Country:US
Mailing Address - Phone:818-530-6000
Mailing Address - Fax:
Practice Address - Street 1:3300 WASHTENAW AVE STE 282
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5184
Practice Address - Country:US
Practice Address - Phone:818-530-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000543103TC0700X
MI6301018030103TC0700X
MI6361007814103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical