Provider Demographics
NPI:1235778374
Name:BERRY, CARISSA NICOLE (LCSWA)
Entity Type:Individual
Prefix:MS
First Name:CARISSA
Middle Name:NICOLE
Last Name:BERRY
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:MRS
Other - First Name:CARISSA
Other - Middle Name:NICOLE
Other - Last Name:CLIFTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3134 WENDELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591
Mailing Address - Country:US
Mailing Address - Phone:919-792-0835
Mailing Address - Fax:919-792-0835
Practice Address - Street 1:3134 WENDELL BLVD
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:NC
Practice Address - Zip Code:27591
Practice Address - Country:US
Practice Address - Phone:919-792-0835
Practice Address - Fax:919-792-0835
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPO14138104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker