Healthcare Provider Details

I. General information

NPI: 1104952837
Provider Name (Legal Business Name): LISA KATHLEEN BERG-ANDERSON M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 TUTTLE AVE
EASTPORT NY
11941-1307
US

IV. Provider business mailing address

42 TUTTLE AVE
EASTPORT NY
11941-1307
US

V. Phone/Fax

Practice location:
  • Phone: 631-898-0261
  • Fax:
Mailing address:
  • Phone: 631-898-0261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number007683-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: