Provider Demographics
NPI:1124473087
Name:BERG, LAURA ANN (MSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:BERG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-474-6842
Mailing Address - Fax:509-474-6606
Practice Address - Street 1:235 E ROWAN AVE STE 107
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1240
Practice Address - Country:US
Practice Address - Phone:509-252-6446
Practice Address - Fax:509-252-6490
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW607963211041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124473087Medicaid