Provider Demographics
NPI:1679733430
Name:BERRY, MARTHA PHOENIX (MA,LPC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:PHOENIX
Last Name:BERRY
Suffix:
Gender:F
Credentials:MA,LPC
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:PHOENIX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA,LPC
Mailing Address - Street 1:31365 COACHLIGHT LN
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4403
Mailing Address - Country:US
Mailing Address - Phone:248-646-3969
Mailing Address - Fax:
Practice Address - Street 1:31365 COACHLIGHT LN
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4403
Practice Address - Country:US
Practice Address - Phone:248-646-3969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-14
Last Update Date:2008-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2684101YP2500X
MI6401007192101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional