Provider Demographics
NPI:1376090498
Name:BERG, SCOTT (ISW 9192)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BERG
Suffix:
Gender:M
Credentials:ISW 9192
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 CARRERA DR
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-9249
Mailing Address - Country:US
Mailing Address - Phone:352-446-0995
Mailing Address - Fax:
Practice Address - Street 1:2140 N DON WICKHAM DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1922
Practice Address - Country:US
Practice Address - Phone:352-394-5322
Practice Address - Fax:352-394-1103
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW91921041C0700X
SW139551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical