Provider Demographics
NPI:1548295785
Name:BERG, LLOYD STUART (PHD)
Entity type:Individual
Prefix:
First Name:LLOYD
Middle Name:STUART
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 1:1601 RIO GRANDE ST STE 340
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1162
Mailing Address - Country:US
Mailing Address - Phone:512-795-5500
Mailing Address - Fax:512-795-3502
Practice Address - Street 1:3501 MILLS AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6309
Practice Address - Country:US
Practice Address - Phone:512-324-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25608103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88061AOtherBCBS
TX096603804Medicaid
TX079974401Medicaid
TX88061AOtherBCBS
TXTXB112859Medicare PIN
TX82640PMedicare ID - Type Unspecified