Provider Demographics
NPI:1982321865
Name:BERG, NICOLE THERESA VI (LICSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:THERESA
Last Name:BERG
Suffix:VI
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CORINTHIAN PL
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5338
Mailing Address - Country:US
Mailing Address - Phone:210-784-0397
Mailing Address - Fax:
Practice Address - Street 1:301 CORINTHIAN PL
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5338
Practice Address - Country:US
Practice Address - Phone:210-784-0397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
FLISW17459101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL409907Medicaid