=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659186708
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLYN BERG MSW, APSW, SAC-IT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2025
-----------------------------------------------------
Last Update Date | 02/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 5TH AVE S STE 508
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-387-9638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 E OLSON ST
-----------------------------------------------------
City | BLAIR
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54616-9307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 20459-130
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6851119332
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number | 17013-137
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 135215-121
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------