Provider Demographics
NPI:1619363207
Name:BERRY, GEORGIA ANNE (MFT)
Entity Type:Individual
Prefix:MS
First Name:GEORGIA
Middle Name:ANNE
Last Name:BERRY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 FARMERS LN
Mailing Address - Street 2:SUITE 15
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6710
Mailing Address - Country:US
Mailing Address - Phone:707-953-8790
Mailing Address - Fax:866-605-1176
Practice Address - Street 1:725 FARMERS LN
Practice Address - Street 2:SUITE 15
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6710
Practice Address - Country:US
Practice Address - Phone:707-953-8790
Practice Address - Fax:866-605-1176
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT81043106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist