Provider Demographics
NPI:1053443168
Name:BERRY, CAROLYN MARIE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:BERRY
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 1:4733 HASKELL AVE
Mailing Address - Street 2:#48
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1616
Mailing Address - Country:US
Mailing Address - Phone:818-986-2123
Mailing Address - Fax:818-986-2123
Practice Address - Street 1:6931 VAN NUYS BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3937
Practice Address - Country:US
Practice Address - Phone:818-909-5870
Practice Address - Fax:818-909-9980
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28911106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist