Provider Demographics
NPI:1992772438
Name:BERG, LEAH ANNE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:ANNE
Last Name:BERG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:ANNE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:160 BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-3414
Mailing Address - Country:US
Mailing Address - Phone:401-724-8400
Mailing Address - Fax:401-722-5280
Practice Address - Street 1:160 BEECHWOOD AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-3414
Practice Address - Country:US
Practice Address - Phone:401-724-8400
Practice Address - Fax:401-722-5280
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW019871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid