Provider Demographics
NPI:1043367758
Name:BERG, STEPHANIE S (LICSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:S
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 1:1600 E OLIVE ST
Mailing Address - Street 2:SEATTLE MENTAL HEALTH
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2735
Mailing Address - Country:US
Mailing Address - Phone:206-302-2200
Mailing Address - Fax:206-302-2210
Practice Address - Street 1:14270 NE 21ST ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3720
Practice Address - Country:US
Practice Address - Phone:425-653-5025
Practice Address - Fax:425-653-5010
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000050061041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB01927Medicare ID - Type Unspecified
S44060Medicare UPIN