Provider Demographics
NPI:1679643381
Name:BERRY, CHARLENE VIVIAN (MSW)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:VIVIAN
Last Name:BERRY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-8050
Mailing Address - Country:US
Mailing Address - Phone:504-366-3630
Mailing Address - Fax:504-341-5094
Practice Address - Street 1:1013 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-8050
Practice Address - Country:US
Practice Address - Phone:504-366-3630
Practice Address - Fax:504-341-5094
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1883101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5S644Medicare ID - Type UnspecifiedLICENSED CERTIFIED SOCIAL