Healthcare Provider Details

I. General information

NPI: 1114948817
Provider Name (Legal Business Name): RICHARD A BERG PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5010 RANDALL PKWY
WILMINGTON NC
28403-2829
US

IV. Provider business mailing address

5010 RANDALL PKWY
WILMINGTON NC
28403-2829
US

V. Phone/Fax

Practice location:
  • Phone: 910-791-5719
  • Fax: 910-799-8180
Mailing address:
  • Phone: 910-791-5719
  • Fax: 910-799-8180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1976
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1976
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: