Provider Demographics
NPI:1568195238
Name:BERRY, ANGELA AILEEN
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:AILEEN
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 1:8025 MEADOWFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-3268
Mailing Address - Country:US
Mailing Address - Phone:618-581-8848
Mailing Address - Fax:
Practice Address - Street 1:1349 MCNUTT ST
Practice Address - Street 2:
Practice Address - City:HERCULANEUM
Practice Address - State:MO
Practice Address - Zip Code:63048-1510
Practice Address - Country:US
Practice Address - Phone:636-638-2203
Practice Address - Fax:636-638-2206
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178012526101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional