Provider Demographics
NPI:1205924743
Name:BERG, SUSAN R (MFT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:BERG
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E. COTATI AVE. SUITE G
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931
Mailing Address - Country:US
Mailing Address - Phone:707-792-9716
Mailing Address - Fax:707-794-8271
Practice Address - Street 1:315 E COTATI AVE STE G
Practice Address - Street 2:
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931-7801
Practice Address - Country:US
Practice Address - Phone:707-792-9716
Practice Address - Fax:707-794-8271
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC17222106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist