Healthcare Provider Details

I. General information

NPI: 1013438449
Provider Name (Legal Business Name): BETHANY LARSON BERG MS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 07/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 E HUNTINGTON DR
MONROVIA CA
91016-3636
US

IV. Provider business mailing address

3210 SAWTELLE BLVD APT 110
LOS ANGELES CA
90066-1607
US

V. Phone/Fax

Practice location:
  • Phone: 626-471-9922
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC000895
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: