Provider Demographics
NPI:1558640052
Name:BERG, NATHAN DAVID (AUD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:DAVID
Last Name:BERG
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11035 WEST FOREST HOME AVENUE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53130
Mailing Address - Country:US
Mailing Address - Phone:414-529-3215
Mailing Address - Fax:
Practice Address - Street 1:11035 W FOREST HOME AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2541
Practice Address - Country:US
Practice Address - Phone:414-529-3215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI566156231H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program