Provider Demographics
NPI:1306386636
Name:BERRY, ELLEN
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:D
Other - Last Name:GUZAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:511 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-2150
Mailing Address - Country:US
Mailing Address - Phone:847-738-6968
Mailing Address - Fax:
Practice Address - Street 1:121 MADISON ST
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-2150
Practice Address - Country:US
Practice Address - Phone:847-738-6968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012474101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional