Provider Demographics
NPI:1073520508
Name:BERRY, CORA S (MA)
Entity Type:Individual
Prefix:
First Name:CORA
Middle Name:S
Last Name:BERRY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MCCOOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-2927
Mailing Address - Country:US
Mailing Address - Phone:308-345-1429
Mailing Address - Fax:308-345-6513
Practice Address - Street 1:812 W 13TH ST
Practice Address - Street 2:
Practice Address - City:MCCOOK
Practice Address - State:NE
Practice Address - Zip Code:69001-2927
Practice Address - Country:US
Practice Address - Phone:308-345-1429
Practice Address - Fax:308-345-6513
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE011101YA0400X
NE393101YM0800X
NE284101YP2500X
KS103101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100249773-00Medicaid