Healthcare Provider Details

I. General information

NPI: 1548295785
Provider Name (Legal Business Name): LLOYD STUART BERG PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 MILLS AVE
AUSTIN TX
78731-6309
US

IV. Provider business mailing address

1601 RIO GRANDE ST STE 340
AUSTIN TX
78701-1162
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-2000
  • Fax:
Mailing address:
  • Phone: 512-795-5500
  • Fax: 512-795-3502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number25608
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: