Healthcare Provider Details

I. General information

NPI: 1902053069
Provider Name (Legal Business Name): MRS. DIANE L BERGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 EVANS AVE
VALPARAISO IN
46383-6940
US

IV. Provider business mailing address

179 SHOREWOOD DR
VALPARAISO IN
46385-7710
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-0786
  • Fax: 219-548-7543
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22004642A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: