Provider Demographics
NPI:1629294897
Name:TRUSSEL BERG, JOANNA LAREE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:JOANNA
Middle Name:LAREE
Last Name:TRUSSEL BERG
Suffix:
Gender:F
Credentials:LCSW
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 372
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-0372
Mailing Address - Country:US
Mailing Address - Phone:208-521-9946
Mailing Address - Fax:
Practice Address - Street 1:1689 E 113 S
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7785
Practice Address - Country:US
Practice Address - Phone:208-521-9946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-338431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical