Provider Demographics
NPI:1457188054
Name:BERG, BRADLEY C (PHD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:C
Last Name:BERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:BRADLEY
Other - Middle Name:C
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:52 PAVILION CIR
Mailing Address - Street 2:
Mailing Address - City:MACKS CREEK
Mailing Address - State:MO
Mailing Address - Zip Code:65786-8361
Mailing Address - Country:US
Mailing Address - Phone:573-286-5625
Mailing Address - Fax:
Practice Address - Street 1:52 PAVILION CIR
Practice Address - Street 2:
Practice Address - City:MACKS CREEK
Practice Address - State:MO
Practice Address - Zip Code:65786-8361
Practice Address - Country:US
Practice Address - Phone:573-286-5625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MONONE101YP1600X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral