Provider Demographics
NPI:1922187822
Name:BERG, HARRY M (LICSW)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:M
Last Name:BERG
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-2100
Mailing Address - Country:US
Mailing Address - Phone:781-963-7775
Mailing Address - Fax:781-963-7776
Practice Address - Street 1:1093 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-2100
Practice Address - Country:US
Practice Address - Phone:781-963-7775
Practice Address - Fax:781-963-7776
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1013361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01913Medicare PIN