Healthcare Provider Details

I. General information

NPI: 1841296977
Provider Name (Legal Business Name): ROBERT CHARLES BERGER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 W PROMENADE ST
MEXICO MO
65265-2719
US

IV. Provider business mailing address

321 W PROMENADE ST
MEXICO MO
65265-2719
US

V. Phone/Fax

Practice location:
  • Phone: 573-582-1234
  • Fax: 573-582-1212
Mailing address:
  • Phone: 573-582-1234
  • Fax: 573-582-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number000544
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: