Provider Demographics
NPI:1720080047
Name:BERG, CHERYL (LCSW)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 255
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-0255
Mailing Address - Country:US
Mailing Address - Phone:207-642-5525
Mailing Address - Fax:
Practice Address - Street 1:5 ORCHARD RD
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:ME
Practice Address - Zip Code:04084-6418
Practice Address - Country:US
Practice Address - Phone:207-642-5525
Practice Address - Fax:207-642-4808
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC 43451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEBEMM 5848Medicare ID - Type Unspecified