Provider Demographics
NPI:1407402886
Name:BERG, TINA MARIE (LPCA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:BERG
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2842 WAXHAW INDIAN TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-4223
Mailing Address - Country:US
Mailing Address - Phone:352-777-8622
Mailing Address - Fax:
Practice Address - Street 1:10801 MONROE RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-8335
Practice Address - Country:US
Practice Address - Phone:352-777-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15062101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health