Provider Demographics
NPI:1831127075
Name:BERRY, FAITH JOANN (LAC)
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:JOANN
Last Name:BERRY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:FAITH JOANN
Other - Middle Name:JOANN
Other - Last Name:MOOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:4253 N CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4593
Mailing Address - Country:US
Mailing Address - Phone:479-521-5731
Mailing Address - Fax:479-521-4926
Practice Address - Street 1:4253 N CROSSOVER RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4593
Practice Address - Country:US
Practice Address - Phone:479-443-6496
Practice Address - Fax:479-521-4926
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0308072101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health