Provider Demographics
NPI:1376222471
Name:BERG, COURTNEY E (RDN)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:E
Last Name:BERG
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12166 OAKVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-5299
Mailing Address - Country:US
Mailing Address - Phone:858-663-9295
Mailing Address - Fax:
Practice Address - Street 1:12166 OAKVIEW WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-5299
Practice Address - Country:US
Practice Address - Phone:858-663-9295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered