Provider Demographics
NPI:1184017444
Name:BERRY, HAZEL
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:
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 1:94235 MOORE ST STE 121
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-9704
Mailing Address - Country:US
Mailing Address - Phone:541-813-2535
Mailing Address - Fax:541-813-2536
Practice Address - Street 1:412 ALDER ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9014
Practice Address - Country:US
Practice Address - Phone:541-813-2535
Practice Address - Fax:541-813-2536
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3692/ACTIVE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health