Healthcare Provider Details

I. General information

NPI: 1750991964
Provider Name (Legal Business Name): GARY LEE BERGER JR. CDCAQ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5577 AIRPORT HWY STE 200
TOLEDO OH
43615-7364
US

IV. Provider business mailing address

5577 AIRPORT HWY STE 200
TOLEDO OH
43615-7364
US

V. Phone/Fax

Practice location:
  • Phone: 419-720-0442
  • Fax:
Mailing address:
  • Phone: 419-720-0442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.175390
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: