Provider Demographics
NPI:1821141888
Name:OSTERBERG, MARTHA JEAN (LICSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JEAN
Last Name:OSTERBERG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W LAKE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2949
Mailing Address - Country:US
Mailing Address - Phone:612-822-3417
Mailing Address - Fax:
Practice Address - Street 1:621 W LAKE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2949
Practice Address - Country:US
Practice Address - Phone:612-822-3417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN108251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16D66OSOtherBLUE CROSS&BLUE SHIELD