Healthcare Provider Details

I. General information

NPI: 1700358561
Provider Name (Legal Business Name): LESLIE LAUREN BERBERICH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11921 E PALMER WASILLA HWY
PALMER AK
99645-8833
US

IV. Provider business mailing address

PO BOX 874583
WASILLA AK
99687-4583
US

V. Phone/Fax

Practice location:
  • Phone: 907-745-2634
  • Fax:
Mailing address:
  • Phone: 907-521-2101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number105341
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: