Provider Demographics
NPI:1629209697
Name:BERG, MADELEINE ELISE (CDN)
Entity Type:Individual
Prefix:MS
First Name:MADELEINE
Middle Name:ELISE
Last Name:BERG
Suffix:
Gender:F
Credentials:CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WINTHROP DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-1315
Mailing Address - Country:US
Mailing Address - Phone:516-312-7565
Mailing Address - Fax:
Practice Address - Street 1:26 WINTHROP DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-1315
Practice Address - Country:US
Practice Address - Phone:516-312-7565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003019133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist