Provider Demographics
NPI:1558834143
Name:BERG, MARIA LAINA (LADC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LAINA
Last Name:BERG
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OLIVIA
Mailing Address - State:MN
Mailing Address - Zip Code:56277-1589
Mailing Address - Country:US
Mailing Address - Phone:320-400-0001
Mailing Address - Fax:320-523-3535
Practice Address - Street 1:104 S 4TH ST
Practice Address - Street 2:
Practice Address - City:OLIVIA
Practice Address - State:MN
Practice Address - Zip Code:56277-1589
Practice Address - Country:US
Practice Address - Phone:320-400-0001
Practice Address - Fax:320-523-3535
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301549101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)