Provider Demographics
NPI:1891422523
Name:BERRY, MAHALA (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:MAHALA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3502
Mailing Address - Country:US
Mailing Address - Phone:608-937-9378
Mailing Address - Fax:
Practice Address - Street 1:39675 CEDAR BLVD STE 220A
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-5491
Practice Address - Country:US
Practice Address - Phone:510-877-0686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29435235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist