Basic Information
| Provider Information | |||||||||
| NPI: | 1013130905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | IMF | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 CRANE BLVD. | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232279260 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 921 W. AVE. J SUITE C | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619490131 | ||||||||
| FaxNumber: | 6617298912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 39482 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | CBSC333 | 01 | CA | LA DMH PROVIDER | OTHER |