Provider Demographics
NPI:1457480196
Name:BERG, SANDRA M
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:M
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MOHAWK LN
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-2712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:260 N LITTLE TOR RD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-2627
Practice Address - Country:US
Practice Address - Phone:845-634-4648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000886235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist