MEDICARE: JOANN MARIE BERGE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS 13250	CA

General Provider Information

NPI Number	:	1932223351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANN MARIE BERGE LCSW

Provider Business Mailing Address
First Line	:	831 STRATFORD ST
Second Line	:
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-2446
Country	:	US
Telephone Number	:	805-773-2724
Fax Number	:

Provider Business Practice Location Address
First Line	:	831 STRATFORD ST
Second Line	:
City	:	PISMO BEACH
State	:	CA
Zip	:	93449-2446
Country	:	US
Telephone Number	:	805-773-2724
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	10/19/2008

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