Healthcare Provider Details

I. General information

NPI: 1205204799
Provider Name (Legal Business Name): AMY E BERG PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NE 2ND ST
GRESHAM OR
97030-7514
US

IV. Provider business mailing address

1776 SW MADISON ST
PORTLAND OR
97205-1715
US

V. Phone/Fax

Practice location:
  • Phone: 971-274-3757
  • Fax: 503-912-5740
Mailing address:
  • Phone: 503-224-1044
  • Fax: 503-621-2235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60333379
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200540554RN
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61012022
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201506290NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: