Provider Demographics
NPI:1982654935
Name:BERGE, MARY B (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:B
Last Name:BERGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:B
Other - Last Name:AUEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1765 GOUCHER ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-1101
Mailing Address - Country:US
Mailing Address - Phone:814-535-8586
Mailing Address - Fax:814-254-4170
Practice Address - Street 1:1765 GOUCHER ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-1101
Practice Address - Country:US
Practice Address - Phone:814-535-8586
Practice Address - Fax:814-254-4170
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015330103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2683283OtherHIGHMARK / BCBS
PA562719Medicaid
PA562719Medicaid