Provider Demographics
NPI:1174333785
Name:RONNEBERG, KAREN MARIE (MSW)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:RONNEBERG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:MARIE
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:2265 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2996
Mailing Address - Country:US
Mailing Address - Phone:208-524-7400
Mailing Address - Fax:
Practice Address - Street 1:2265 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2996
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6371144104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker