Provider Demographics
NPI:1821017864
Name:BERRY, DIANE L (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:BERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027
Mailing Address - Country:US
Mailing Address - Phone:503-650-4359
Mailing Address - Fax:503-650-6913
Practice Address - Street 1:8305 SE MONTEREY
Practice Address - Street 2:#220
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266
Practice Address - Country:US
Practice Address - Phone:503-650-4359
Practice Address - Fax:503-650-6913
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000TLFBPMedicare ID - Type Unspecified