Provider Demographics
NPI:1710423298
Name:BERRY, GOLDEN KEITH SR (BS)
Entity Type:Individual
Prefix:
First Name:GOLDEN
Middle Name:KEITH
Last Name:BERRY
Suffix:SR
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-3529
Mailing Address - Country:US
Mailing Address - Phone:318-537-1118
Mailing Address - Fax:
Practice Address - Street 1:1705 FELICIA AVE
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-8203
Practice Address - Country:US
Practice Address - Phone:318-574-1232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2024-01-29
Deactivation Date:2023-11-10
Deactivation Code:
Reactivation Date:2024-01-19
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator