Basic Information
| Provider Information | |||||||||
| NPI: | 1821173329 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERG | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | RANAE | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3989 CENTRAL AVE NE | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | COLUMBIA HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554213900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126251500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 S 2ND ST | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126251500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 07/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP4299 | MN | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | LP4299 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 106H00000X | LMFT 0487 | MN | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 984151027400 | 01 | MN | PREFERREDONE | OTHER | 307193600 | 05 | MN | MEDICAID | HP48975 | 01 | MN | HEALTHPARTNERS | OTHER |