Healthcare Provider Details

I. General information

NPI: 1083946909
Provider Name (Legal Business Name): GORDON MARK BERGER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 WESTWOOD BLVD SUITE 106
LOS ANGELES CA
90024-5621
US

IV. Provider business mailing address

1626 WESTWOOD BLVD SUITE 106
LOS ANGELES CA
90024-5621
US

V. Phone/Fax

Practice location:
  • Phone: 310-475-3376
  • Fax: 310-475-4704
Mailing address:
  • Phone: 310-475-3376
  • Fax: 310-475-4704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberRP40
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: