Provider Demographics
NPI:1487711511
Name:BERG, THEODORE F (PHD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:F
Last Name:BERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 N RITCHIE CT APT 908
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2155
Mailing Address - Country:US
Mailing Address - Phone:510-918-2650
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD
Practice Address - Street 2:SUITE 1453
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3606
Practice Address - Country:US
Practice Address - Phone:510-918-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009362103T00000X
CA17341103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist