Provider Demographics
NPI:1932223351
Name:BERGE, JOANN MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:MARIE
Last Name:BERGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JOANN
Other - Middle Name:
Other - Last Name:BREI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:831 STRATFORD ST
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2446
Mailing Address - Country:US
Mailing Address - Phone:805-773-2724
Mailing Address - Fax:
Practice Address - Street 1:831 STRATFORD ST
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2446
Practice Address - Country:US
Practice Address - Phone:805-773-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2008-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 132501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P69919Medicare UPIN
ZZZ24363ZMedicare ID - Type Unspecified