Provider Demographics
NPI:1639477532
Name:BERRY SIMON, MARJORIE LORRAINE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:LORRAINE
Last Name:BERRY SIMON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:LORRAINE
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5473 KEARNY VILLA RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1142
Mailing Address - Country:US
Mailing Address - Phone:619-605-9412
Mailing Address - Fax:
Practice Address - Street 1:5473 KEARNY VILLA RD STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1142
Practice Address - Country:US
Practice Address - Phone:196-605-9412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33331101YM0800X
937811041C0700X
CA1153971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health