Provider Demographics
NPI:1558703272
Name:BERRY, SHARINE NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:SHARINE
Middle Name:NICOLE
Last Name:BERRY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 183053
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48318-3053
Mailing Address - Country:US
Mailing Address - Phone:248-929-2207
Mailing Address - Fax:
Practice Address - Street 1:13854 LAKESIDE CIR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1443
Practice Address - Country:US
Practice Address - Phone:248-403-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI4151001099106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other