Healthcare Provider Details

I. General information

NPI: 1942024534
Provider Name (Legal Business Name): BRIANNA BERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16180 HASTINGS AVE SE
PRIOR LAKE MN
55372-9227
US

IV. Provider business mailing address

16180 HASTINGS AVE SE
PRIOR LAKE MN
55372-9227
US

V. Phone/Fax

Practice location:
  • Phone: 952-443-4600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5711
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: