Provider Demographics
NPI:1164032215
Name:BERRY, CHRISTINE ANN
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ANN
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 1:42220 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-8991
Mailing Address - Country:US
Mailing Address - Phone:414-581-3641
Mailing Address - Fax:
Practice Address - Street 1:42220 N CENTER ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-8991
Practice Address - Country:US
Practice Address - Phone:414-581-3641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7594101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional