Provider Demographics
NPI:1942537170
Name:BERG, TIFFANY J (SAC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:J
Last Name:BERG
Suffix:
Gender:F
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-1222
Mailing Address - Country:US
Mailing Address - Phone:715-723-5585
Mailing Address - Fax:715-726-3504
Practice Address - Street 1:2661 COUNTY HIGHWAY I
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-5407
Practice Address - Country:US
Practice Address - Phone:715-723-5585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15524-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)