MEDICARE: DR. THEODORE F. BERG PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	071.009362	IL
2	103T00000X	Psychologist	17341	CA

General Provider Information

NPI Number	:	1487711511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE F. BERG PH.D.

Provider Business Mailing Address
First Line	:	1313 N RITCHIE CT APT 908
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-2155
Country	:	US
Telephone Number	:	510-918-2650
Fax Number	:

Provider Business Practice Location Address
First Line	:	53 W JACKSON BLVD
Second Line	:	SUITE 1453
City	:	CHICAGO
State	:	IL
Zip	:	60604-3606
Country	:	US
Telephone Number	:	510-918-2650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/01/2007
Last Update Date	:	12/09/2016

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