Healthcare Provider Details

I. General information

NPI: 1225492770
Provider Name (Legal Business Name): MICHAEL BERBER RADT-1
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3576 ARLINGTON AVE STE 102
RIVERSIDE CA
92506-3943
US

IV. Provider business mailing address

3576 ARLINGTON AVE STE 102
RIVERSIDE CA
92506-3943
US

V. Phone/Fax

Practice location:
  • Phone: 951-782-9577
  • Fax:
Mailing address:
  • Phone: 951-782-9577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1221071215
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: