Provider Demographics
NPI:1609975531
Name:BERG, BRADLEY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:BERG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CRUM ELBOW ROAD
Mailing Address - Street 2:FAMILY PRACTICE CENTER OF HYDE PARK
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538
Mailing Address - Country:US
Mailing Address - Phone:845-229-1020
Mailing Address - Fax:845-229-2005
Practice Address - Street 1:11 CRUM ELBOW ROAD
Practice Address - Street 2:FAMILY PRACTICE CENTER OF HYDE PARK
Practice Address - City:HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:12538
Practice Address - Country:US
Practice Address - Phone:845-229-1020
Practice Address - Fax:845-229-2005
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO36212-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00733871Medicaid
NYW08221OtherGROUP #
NY00733871Medicaid