Provider Demographics
NPI:1316039357
Name:BERKER, ENNIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:ENNIS
Middle Name:
Last Name:BERKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 MERLIN WAY
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MI
Mailing Address - Zip Code:48130-9834
Mailing Address - Country:US
Mailing Address - Phone:269-217-2992
Mailing Address - Fax:734-623-0108
Practice Address - Street 1:1008 MERLIN WAY
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-9834
Practice Address - Country:US
Practice Address - Phone:269-217-2992
Practice Address - Fax:734-623-0108
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301 006050103G00000X
MI6301006050103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC 94573OtherBLUE CROSS
MIC 94573OtherBLUE CROSS
MI370741OtherMAGELLAN
MIB OMO 9810Medicare ID - Type UnspecifiedMEDICARE
MIC 94573OtherBLUE CROSS