Provider Demographics
NPI:1528384864
Name:BERRY, RICHARD CECIL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:CECIL
Last Name:BERRY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 CHEYENNE RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6104
Mailing Address - Country:US
Mailing Address - Phone:757-490-3996
Mailing Address - Fax:757-490-3996
Practice Address - Street 1:297 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 126
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-2911
Practice Address - Country:US
Practice Address - Phone:757-385-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904000073371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861562472Medicaid