Provider Demographics
NPI:1629251442
Name:BERRY-EVANS, MATTYE L
Entity Type:Individual
Prefix:MS
First Name:MATTYE
Middle Name:L
Last Name:BERRY-EVANS
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 1:325 E PIONEER AVE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3265
Mailing Address - Country:US
Mailing Address - Phone:253-697-8400
Mailing Address - Fax:253-697-8392
Practice Address - Street 1:325 E PIONEER AVE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3265
Practice Address - Country:US
Practice Address - Phone:253-697-8400
Practice Address - Fax:253-697-8392
Is Sole Proprietor?:No
Enumeration Date:2007-12-14
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00015634101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health