Healthcare Provider Details

I. General information

NPI: 1639742901
Provider Name (Legal Business Name): COREY BERG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6024 PEREGRINE AVE
ORLANDO FL
32819-7520
US

IV. Provider business mailing address

354 MERRIMACK ST STE 395
LAWRENCE MA
01843-1754
US

V. Phone/Fax

Practice location:
  • Phone: 954-559-3325
  • Fax:
Mailing address:
  • Phone: 774-206-1125
  • Fax: 774-628-9657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: