Provider Demographics
NPI:1487682241
Name:BERG, DOROTHY E (PH D)
Entity type:Individual
Prefix:DR
First Name:DOROTHY
Middle Name:E
Last Name:BERG
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5250 NORTHLAND DR NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1040
Mailing Address - Country:US
Mailing Address - Phone:616-361-5001
Mailing Address - Fax:616-361-2166
Practice Address - Street 1:5250 NORTHLAND DR NE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1040
Practice Address - Country:US
Practice Address - Phone:616-361-5001
Practice Address - Fax:616-361-2166
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005572103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0D145595682Medicare ID - Type Unspecified
R67321Medicare UPIN