Provider Demographics
NPI:1578137410
Name:BERRY, KEELY MARIE
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:MARIE
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 1:323 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-1071
Mailing Address - Country:US
Mailing Address - Phone:989-390-3563
Mailing Address - Fax:
Practice Address - Street 1:5039 VILLA LINDE PKWY STE 30
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3450
Practice Address - Country:US
Practice Address - Phone:989-401-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-15
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician