Provider Demographics
NPI:1629595228
Name:BERG, MARY CAMILLE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAMILLE
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 1:1408 20TH AVE SW STE 7
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-6494
Mailing Address - Country:US
Mailing Address - Phone:701-858-0009
Mailing Address - Fax:701-839-0610
Practice Address - Street 1:1408 20TH AVE SW STE 7
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6494
Practice Address - Country:US
Practice Address - Phone:701-858-0009
Practice Address - Fax:701-838-0610
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician