Provider Demographics
NPI:1578971065
Name:BERRY, GROVER III (AA MANAGEMENT)
Entity Type:Individual
Prefix:
First Name:GROVER
Middle Name:
Last Name:BERRY
Suffix:III
Gender:M
Credentials:AA MANAGEMENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3360 N RANCHO DR. STE.113
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130
Mailing Address - Country:US
Mailing Address - Phone:702-982-2928
Mailing Address - Fax:
Practice Address - Street 1:3660 N RANCHO DR STE 113
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3188
Practice Address - Country:US
Practice Address - Phone:702-982-2928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist