Provider Demographics
NPI:1821173329
Name:BERG, DIANNE RANAE (PHD)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:RANAE
Last Name:BERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3989 CENTRAL AVE NE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-3900
Mailing Address - Country:US
Mailing Address - Phone:612-625-1500
Mailing Address - Fax:
Practice Address - Street 1:1300 S 2ND ST
Practice Address - Street 2:SUITE 180
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1075
Practice Address - Country:US
Practice Address - Phone:612-625-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4299103T00000X, 103TC0700X
MNLMFT 0487106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN984151027400OtherPREFERREDONE
MN307193600Medicaid
MNHP48975OtherHEALTHPARTNERS
MNHP48975OtherHEALTHPARTNERS