Provider Demographics
NPI:1497212013
Name:BERRY, NICHOLAS ALEXANDER (LMFT 108674)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALEXANDER
Last Name:BERRY
Suffix:
Gender:M
Credentials:LMFT 108674
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S ORANGE DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3011
Mailing Address - Country:US
Mailing Address - Phone:760-220-2413
Mailing Address - Fax:
Practice Address - Street 1:2001 S BARRINGTON AVE STE 203
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5385
Practice Address - Country:US
Practice Address - Phone:978-400-3206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC108674101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health