Healthcare Provider Details

I. General information

NPI: 1609975531
Provider Name (Legal Business Name): BRADLEY BERG LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 CRUM ELBOW ROAD FAMILY PRACTICE CENTER OF HYDE PARK
HYDE PARK NY
12538
US

IV. Provider business mailing address

11 CRUM ELBOW ROAD FAMILY PRACTICE CENTER OF HYDE PARK
HYDE PARK NY
12538
US

V. Phone/Fax

Practice location:
  • Phone: 845-229-1020
  • Fax: 845-229-2005
Mailing address:
  • Phone: 845-229-1020
  • Fax: 845-229-2005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberRO36212-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: