Provider Demographics
NPI:1689247702
Name:BERRY, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
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 1:1050 BEN RD APT 7
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-3900
Mailing Address - Country:US
Mailing Address - Phone:304-769-8077
Mailing Address - Fax:
Practice Address - Street 1:1050 BEN RD APT 7
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-3900
Practice Address - Country:US
Practice Address - Phone:304-769-8077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health