Healthcare Provider Details

I. General information

NPI: 1205924743
Provider Name (Legal Business Name): SUSAN R. BERG MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E COTATI AVE STE G
COTATI CA
94931-7801
US

IV. Provider business mailing address

315 E. COTATI AVE. SUITE G
COTATI CA
94931
US

V. Phone/Fax

Practice location:
  • Phone: 707-792-9716
  • Fax: 707-794-8271
Mailing address:
  • Phone: 707-792-9716
  • Fax: 707-794-8271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC17222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: