Provider Demographics
NPI:1407202559
Name:BERG, BONNIE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:BERG
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 1:702 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914
Mailing Address - Country:US
Mailing Address - Phone:541-889-9167
Mailing Address - Fax:
Practice Address - Street 1:290 WILLAMETTE ST
Practice Address - Street 2:
Practice Address - City:UMATILLA
Practice Address - State:OR
Practice Address - Zip Code:97882-6601
Practice Address - Country:US
Practice Address - Phone:541-922-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-08
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health