Provider Demographics
NPI:1639865876
Name:BERG, MADISON RAE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:RAE
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 1:4832 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-8009
Mailing Address - Country:US
Mailing Address - Phone:402-649-8326
Mailing Address - Fax:
Practice Address - Street 1:620 E 25TH ST STE 7
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-5529
Practice Address - Country:US
Practice Address - Phone:308-455-1781
Practice Address - Fax:308-455-1782
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2719235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist