Provider Demographics
NPI:1376124701
Name:BERRY, MADELYN ROSE
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:ROSE
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 1:239 DALE RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-2930
Mailing Address - Country:US
Mailing Address - Phone:443-370-9333
Mailing Address - Fax:
Practice Address - Street 1:2288 BLUE WATER BLVD STE 310
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-3301
Practice Address - Country:US
Practice Address - Phone:844-244-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-17
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst