Provider Demographics
NPI:1003516741
Name:BERRY, SHANDA (MS, LCGC)
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 HAMAKER CT STE 330
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2243
Mailing Address - Country:US
Mailing Address - Phone:571-282-3923
Mailing Address - Fax:
Practice Address - Street 1:3025 HAMAKER CT STE 330
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2243
Practice Address - Country:US
Practice Address - Phone:571-282-3923
Practice Address - Fax:571-730-4091
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20513170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS