Provider Demographics
NPI:1093805889
Name:BERRY, LAWRENCE (MA, LCMHC)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 DUCHESS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-5516
Mailing Address - Country:US
Mailing Address - Phone:802-334-6744
Mailing Address - Fax:
Practice Address - Street 1:154 DUCHESS AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-5516
Practice Address - Country:US
Practice Address - Phone:802-334-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-000390103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT63V025OtherMVP
VT1007040Medicaid
VT00038296OtherBCBS
VT2019225OtherCIGNA