Provider Demographics
NPI:1861829996
Name:BERRY, ALEXANDER J
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:J
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 1:165 E HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2629
Mailing Address - Country:US
Mailing Address - Phone:509-684-4597
Mailing Address - Fax:509-684-5286
Practice Address - Street 1:301 E CLAY AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109-8936
Practice Address - Country:US
Practice Address - Phone:509-935-4808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61036450101Y00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor