Provider Demographics
NPI:1164790218
Name:BERK, TRAVIS MANNING (MA, LMFT, LCASA)
Entity Type:Individual
Prefix:MRS
First Name:TRAVIS
Middle Name:MANNING
Last Name:BERK
Suffix:
Gender:F
Credentials:MA, LMFT, LCASA
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:TRAVIS
Other - Last Name:MANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LMFT, LCASA
Mailing Address - Street 1:284 EXECUTIVE PARK DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1894
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:
Practice Address - Street 1:132 POPLAR GROVE CONNECTOR
Practice Address - Street 2:SUITE # B
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5915
Practice Address - Country:US
Practice Address - Phone:828-264-8759
Practice Address - Fax:828-268-0201
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NC3321-A101YA0400X
NC1606106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)