Provider Demographics
NPI:1932525201
Name:BERG, DOMINICK S (PC)
Entity Type:Individual
Prefix:MR
First Name:DOMINICK
Middle Name:S
Last Name:BERG
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 PARK AVE W STE 2
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2719
Mailing Address - Country:US
Mailing Address - Phone:419-522-6191
Mailing Address - Fax:
Practice Address - Street 1:1404 PARK AVE W STE 2
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-2719
Practice Address - Country:US
Practice Address - Phone:419-522-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0297823Medicaid