Provider Demographics
NPI:1578029906
Name:BERRY, DEBORAH G
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:G
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:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:NM
Mailing Address - Zip Code:88065-0523
Mailing Address - Country:US
Mailing Address - Phone:575-590-7752
Mailing Address - Fax:
Practice Address - Street 1:131 OLD RANCH ROAD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:NM
Practice Address - Zip Code:88065
Practice Address - Country:US
Practice Address - Phone:575-590-7752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMHO148821101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health