Healthcare Provider Details

I. General information

NPI: 1295156495
Provider Name (Legal Business Name): LEA BERENTSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10110 LAKE ROAD
BOTTINEAU ND
58318
US

IV. Provider business mailing address

PO BOX 267
BOTTINEAU ND
58318-0267
US

V. Phone/Fax

Practice location:
  • Phone: 701-389-7963
  • Fax: 701-425-0550
Mailing address:
  • Phone: 701-389-7963
  • Fax: 701-425-0550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number487
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number487
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: