Provider Demographics
NPI:1811404296
Name:BERBAUM, LONI
Entity Type:Individual
Prefix:
First Name:LONI
Middle Name:
Last Name:BERBAUM
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 1:6100 KITAMAYA ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-1765
Mailing Address - Country:US
Mailing Address - Phone:217-621-4124
Mailing Address - Fax:
Practice Address - Street 1:6100 KITAMAYA ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-1765
Practice Address - Country:US
Practice Address - Phone:217-621-4124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-06
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-2290235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty