Provider Demographics
NPI:1639742901
Name:BERG, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:BERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 MERRIMACK ST STE 395
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1754
Mailing Address - Country:US
Mailing Address - Phone:774-206-1125
Mailing Address - Fax:774-628-9657
Practice Address - Street 1:6024 PEREGRINE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7520
Practice Address - Country:US
Practice Address - Phone:954-559-3325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health