Provider Demographics
NPI:1063006260
Name:BERRY, DAVON
Entity Type:Individual
Prefix:
First Name:DAVON
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2812
Mailing Address - Country:US
Mailing Address - Phone:718-812-3911
Mailing Address - Fax:
Practice Address - Street 1:114 LOWELL AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-2812
Practice Address - Country:US
Practice Address - Phone:718-812-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician