Provider Demographics
NPI:1609545219
Name:BERRY, KEITH SR
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BERRY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20200 GLADSTONE RD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-6646
Mailing Address - Country:US
Mailing Address - Phone:216-479-9525
Mailing Address - Fax:
Practice Address - Street 1:398 W BAGLEY RD STE 216
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-1312
Practice Address - Country:US
Practice Address - Phone:216-340-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health