Provider Demographics
NPI:1740590124
Name:BERRY, TEDDY WAYNE
Entity Type:Individual
Prefix:
First Name:TEDDY
Middle Name:WAYNE
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 SW 63RD ST.
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139
Mailing Address - Country:US
Mailing Address - Phone:405-574-6551
Mailing Address - Fax:
Practice Address - Street 1:936 SW 63RD ST.
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139
Practice Address - Country:US
Practice Address - Phone:405-574-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health