Provider Demographics
NPI:1871966994
Name:BERCUSON, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BERCUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 62ND ST
Mailing Address - Street 2:APT 204
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1280
Mailing Address - Country:US
Mailing Address - Phone:510-841-1262
Mailing Address - Fax:
Practice Address - Street 1:1950 ADDISON ST
Practice Address - Street 2:SUITE 109
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1176
Practice Address - Country:US
Practice Address - Phone:510-841-1262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program