Provider Demographics
NPI:1598750796
Name:BERG, GAYLE R (PHD)
Entity Type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:R
Last Name:BERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:70 GLEN COVE RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:ROSLYN HTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1726
Mailing Address - Country:US
Mailing Address - Phone:516-621-0888
Mailing Address - Fax:516-626-1843
Practice Address - Street 1:70 GLEN COVE RD
Practice Address - Street 2:SUITE 209
Practice Address - City:ROSLYN HTS
Practice Address - State:NY
Practice Address - Zip Code:11577-1726
Practice Address - Country:US
Practice Address - Phone:516-621-0888
Practice Address - Fax:516-626-1843
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2011-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007919-1103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV21981Medicare ID - Type Unspecified