Provider Demographics
NPI:1003423187
Name:BERBERICH, KACEY ALLISON
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:ALLISON
Last Name:BERBERICH
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 1:528 W J ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3045
Mailing Address - Country:US
Mailing Address - Phone:925-286-5458
Mailing Address - Fax:
Practice Address - Street 1:12901 SE 97TH AVE STE 340
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7903
Practice Address - Country:US
Practice Address - Phone:503-655-8045
Practice Address - Fax:503-655-6806
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician