Provider Demographics
NPI:1366518813
Name:BERG, BONNIE JAN (LCSW)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:JAN
Last Name:BERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SW TAYLOR ST
Mailing Address - Street 2:SUITE 650
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2543
Mailing Address - Country:US
Mailing Address - Phone:503-224-4654
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST
Practice Address - Street 2:SUITE 650
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2543
Practice Address - Country:US
Practice Address - Phone:503-224-4654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR40651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical