Provider Demographics
NPI:1679622005
Name:BERRY, JAMES T (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:T
Last Name:BERRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 EBENEZER RD
Mailing Address - Street 2:EBENEZER COUNSELING SERVICES
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923
Mailing Address - Country:US
Mailing Address - Phone:465-670-0988
Mailing Address - Fax:865-670-1991
Practice Address - Street 1:325 EBENEZER RD
Practice Address - Street 2:EBENEZER COUNSELING SERVICES
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923
Practice Address - Country:US
Practice Address - Phone:465-670-0988
Practice Address - Fax:865-670-1991
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP2079103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3980497Medicaid
TN3045949OtherBCBS
TN3980497Medicaid