Provider Demographics
NPI:1679195218
Name:BERRY, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:BERRY
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 1:514 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3631
Mailing Address - Country:US
Mailing Address - Phone:262-970-6639
Mailing Address - Fax:
Practice Address - Street 1:2727 N GRANDVIEW BLVD STE 205
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1671
Practice Address - Country:US
Practice Address - Phone:262-547-5567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-16
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional