Provider Demographics
NPI:1184156879
Name:BERGER, BENJAMIN L (OT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:L
Last Name:BERGER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12201 RENFERT WAY STE 115
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5367
Mailing Address - Country:US
Mailing Address - Phone:512-551-0375
Mailing Address - Fax:512-551-0634
Practice Address - Street 1:12201 RENFERT WAY STE 115
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5367
Practice Address - Country:US
Practice Address - Phone:512-551-0375
Practice Address - Fax:512-551-0634
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117244225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist