Provider Demographics
NPI:1407831431
Name:BERG, KATHRYN J (LICSW)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:J
Last Name:BERG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 SINGLETREE LN
Mailing Address - Street 2:SUITE 204
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5328
Mailing Address - Country:US
Mailing Address - Phone:952-914-0384
Mailing Address - Fax:
Practice Address - Street 1:11800 SINGLETREE LN
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5397
Practice Address - Country:US
Practice Address - Phone:952-914-0384
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN035471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP27318OtherHEALTHPARTNERS
MN62-11498OtherMEDICA
MN79455OtherCIGNA
MN8G209BEOtherBLUE CROSS BLUE SHIELD