Provider Demographics
NPI:1407906381
Name:BERG, TINA MARIE (MA, CCC-A)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:BERG
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 NE MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-2084
Mailing Address - Country:US
Mailing Address - Phone:406-538-5072
Mailing Address - Fax:406-538-5059
Practice Address - Street 1:625 NE MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-2084
Practice Address - Country:US
Practice Address - Phone:406-538-5072
Practice Address - Fax:406-538-5059
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTAU1068231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000290458Medicare UPIN