Provider Demographics
NPI:1497747083
Name:BERG, LACI (LMP)
Entity Type:Individual
Prefix:
First Name:LACI
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 731269
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0060
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:606 120TH AVE NE STE D100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005
Practice Address - Country:US
Practice Address - Phone:425-688-0223
Practice Address - Fax:425-688-0323
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017583225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0378345OtherDEPT OF L&I
WA8939681OtherCRIME VICTIMS
WA7130MOOtherREGENCE BS