Provider Demographics
NPI:1669134946
Name:BERG, MADDISON M (MA)
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:M
Last Name:BERG
Suffix:
Gender:
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3359 WARNER LN
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-9261
Mailing Address - Country:US
Mailing Address - Phone:952-649-0461
Mailing Address - Fax:
Practice Address - Street 1:1600 UNIVERSITY AVE W STE 12
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3952
Practice Address - Country:US
Practice Address - Phone:651-233-1481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC03575101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health