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General NPI Number Information
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NPI Number | 1487711511
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Entity Type | Individual
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Provider Name | THEODORE F. BERG PH.D.
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Gender | Male
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Dates
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Enumeration Date | 01/01/2007
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Last Update Date | 12/09/2016
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Provider Practice Location Address
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Address Line | 53 W JACKSON BLVD SUITE 1453
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City | CHICAGO
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State | IL
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Zip | 60604-3606
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Country | US
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Telephone | 510-918-2650
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Fax |
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Provider Business Mailing Address
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Address Line | 1313 N RITCHIE CT APT 908
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City | CHICAGO
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State | IL
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Zip | 60610-2155
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Country | US
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Telephone | 510-918-2650
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 071.009362
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 17341
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License Number State | CA
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