Provider Demographics
NPI:1306832449
Name:BERG, GINNY (LCSW)
Entity Type:Individual
Prefix:
First Name:GINNY
Middle Name:
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 1:1975 E SUNRISE BLVD
Mailing Address - Street 2:SUITE 614
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1433
Mailing Address - Country:US
Mailing Address - Phone:954-767-8263
Mailing Address - Fax:954-467-1417
Practice Address - Street 1:1975 E SUNRISE BLVD
Practice Address - Street 2:SUITE 614
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1433
Practice Address - Country:US
Practice Address - Phone:954-767-8263
Practice Address - Fax:954-467-1417
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 38741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ6648Medicare ID - Type Unspecified