Provider Demographics
NPI:1396829065
Name:BERG, STACY ANN (LPC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:BERG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ANN
Other - Last Name:MARKUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-3820
Mailing Address - Country:US
Mailing Address - Phone:918-588-1900
Mailing Address - Fax:918-582-6405
Practice Address - Street 1:550 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-3820
Practice Address - Country:US
Practice Address - Phone:918-588-1900
Practice Address - Fax:918-582-6405
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3570101YP2500X
OK21410447174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200566570 AMedicaid