Provider Demographics
NPI:1134558919
Name:BERG, LAURA (LADC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSAC
Mailing Address - Street 1:1600 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-3100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53585 NOKOMIS RD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-4272
Practice Address - Country:US
Practice Address - Phone:715-682-7137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16044-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)