Provider Demographics
NPI:1447374525
Name:BERGER, DAN (EDD, ABPP)
Entity type:Individual
Prefix:DR
First Name:DAN
Middle Name:
Last Name:BERGER
Suffix:
Gender:M
Credentials:EDD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 WOODBINE AVE
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1544
Mailing Address - Country:US
Mailing Address - Phone:631-751-4340
Mailing Address - Fax:631-689-0451
Practice Address - Street 1:38 WOODBINE AVE
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1544
Practice Address - Country:US
Practice Address - Phone:631-751-4340
Practice Address - Fax:631-689-0451
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4343103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00393646Medicaid
NY00393646Medicaid