Provider Demographics
NPI:1750991964
Name:BERGER, GARY LEE JR (CDCAQ)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEE
Last Name:BERGER
Suffix:JR
Gender:M
Credentials:CDCAQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E MARKET ST FL 3
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4535
Mailing Address - Country:US
Mailing Address - Phone:419-222-4474
Mailing Address - Fax:419-222-7044
Practice Address - Street 1:311 E MARKET ST FL 3
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4535
Practice Address - Country:US
Practice Address - Phone:419-222-4474
Practice Address - Fax:419-222-7044
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.172205101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)