Healthcare Provider Details

I. General information

NPI: 1376090498
Provider Name (Legal Business Name): SCOTT BERG ISW 9192
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 N DON WICKHAM DR
CLERMONT FL
34711-1922
US

IV. Provider business mailing address

528 CARRERA DR
LADY LAKE FL
32159-9249
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-5322
  • Fax: 352-394-1103
Mailing address:
  • Phone: 352-446-0995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW9192
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13955
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: