Provider Demographics
NPI:1194467217
Name:BERRY, ALTHEA
Entity Type:Individual
Prefix:
First Name:ALTHEA
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 1:1855 ENGBERG LN
Mailing Address - Street 2:
Mailing Address - City:PHELPS
Mailing Address - State:WI
Mailing Address - Zip Code:54554-9463
Mailing Address - Country:US
Mailing Address - Phone:715-853-2884
Mailing Address - Fax:
Practice Address - Street 1:2738 MANITOWOC RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6630
Practice Address - Country:US
Practice Address - Phone:920-600-9204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-09
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician