Provider Demographics
NPI:1427028489
Name:BERRY, ELOISE J (PHD)
Entity Type:Individual
Prefix:
First Name:ELOISE
Middle Name:J
Last Name:BERRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 S BRYN MAWR AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3216
Mailing Address - Country:US
Mailing Address - Phone:610-525-4828
Mailing Address - Fax:
Practice Address - Street 1:14 S BRYN MAWR AVE STE 205
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3216
Practice Address - Country:US
Practice Address - Phone:610-525-4828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00415300103TC1900X
NJSI00415300103TC2200X
PAPS-018232103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0060836Medicaid