Provider Demographics
NPI:1184228009
Name:BERG, RENAE ANN (LADC)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:ANN
Last Name:BERG
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:RENAE
Other - Middle Name:ANN
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:206 MAPLE AVE E
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1311
Mailing Address - Country:US
Mailing Address - Phone:320-679-3580
Mailing Address - Fax:
Practice Address - Street 1:206 MAPLE AVE E
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1311
Practice Address - Country:US
Practice Address - Phone:132-067-9358
Practice Address - Fax:320-679-3579
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
MN301066101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)