Provider Demographics
NPI:1295395572
Name:BERG, MATTHEW (BCBA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BERG
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 S SHIELDS DR
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-8307
Mailing Address - Country:US
Mailing Address - Phone:847-731-5736
Mailing Address - Fax:
Practice Address - Street 1:1530 S SHIELDS DR
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-8307
Practice Address - Country:US
Practice Address - Phone:847-731-5736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-22-59463103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-22-59463OtherBEHAVIOR ANALYST CERTIFICATION BOARD