Provider Demographics
NPI:1205426046
Name:OBERG, MADELINE GRACE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:GRACE
Last Name:OBERG
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 1:25177 NW 176TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-9878
Mailing Address - Country:US
Mailing Address - Phone:352-448-1614
Mailing Address - Fax:
Practice Address - Street 1:4421 NW 39TH AVE STE 3
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-7221
Practice Address - Country:US
Practice Address - Phone:352-448-1614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20603101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health