Healthcare Provider Details

I. General information

NPI: 1740823558
Provider Name (Legal Business Name): MADELEINE BERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2019
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 E WALNUT ST
COLUMBIA MO
65201-4944
US

IV. Provider business mailing address

1209 E WALNUT ST
COLUMBIA MO
65201-4944
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 855-832-6727
  • Fax: 813-337-0937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-24-15289
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: