Healthcare Provider Details

I. General information

NPI: 1396829065
Provider Name (Legal Business Name): STACY ANN BERG LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY ANN MARKUM

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S PEORIA AVE
TULSA OK
74120-3820
US

IV. Provider business mailing address

550 S PEORIA AVE
TULSA OK
74120-3820
US

V. Phone/Fax

Practice location:
  • Phone: 918-588-1900
  • Fax: 918-582-6405
Mailing address:
  • Phone: 918-588-1900
  • Fax: 918-582-6405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3570
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number21410447
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: