Provider Demographics
NPI:1578393377
Name:BERG, BROC
Entity type:Individual
Prefix:
First Name:BROC
Middle Name:
Last Name:BERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5422 W THUNDERBIRD RD STE 2
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4717
Mailing Address - Country:US
Mailing Address - Phone:615-376-0034
Mailing Address - Fax:
Practice Address - Street 1:5422 W THUNDERBIRD RD STE 2
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4717
Practice Address - Country:US
Practice Address - Phone:615-376-0034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician