Provider Demographics
NPI:1720682628
Name:BERKOWITZ, SARAH
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:BERKOWITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11063 11TH ST N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-9649
Mailing Address - Country:US
Mailing Address - Phone:651-497-1613
Mailing Address - Fax:
Practice Address - Street 1:11063 11TH ST N
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-9649
Practice Address - Country:US
Practice Address - Phone:651-497-1613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2944-29133V00000X
133VN1004X, 133VN1201X, 133VN1501X
MN3584133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2944-29OtherWISCONSIN BOARD OF SAFETY AND PROFESSIONAL SERVICES
MN3584OtherMINNESOTA BOARD OF DIETETICS AND NUTRITION SERVICES