Provider Demographics
NPI:1568122604
Name:BERG, LAURIE (MT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7640 S LOUISE AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5999
Mailing Address - Country:US
Mailing Address - Phone:605-941-2747
Mailing Address - Fax:
Practice Address - Street 1:7640 S LOUISE AVE STE 110
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5999
Practice Address - Country:US
Practice Address - Phone:605-941-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT11695225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist