Provider Demographics
NPI:1891182531
Name:BERRY, GENEAN D (LAC)
Entity Type:Individual
Prefix:MS
First Name:GENEAN
Middle Name:D
Last Name:BERRY
Suffix:
Gender:F
Credentials:LAC
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 7223
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-0223
Mailing Address - Country:US
Mailing Address - Phone:973-698-0449
Mailing Address - Fax:
Practice Address - Street 1:184 N 7TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1610
Practice Address - Country:US
Practice Address - Phone:973-698-0449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00111100171100000X
NY005377171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist