Provider Demographics
NPI:1942672761
Name:BERRY, DEVORIA KEATON
Entity Type:Individual
Prefix:
First Name:DEVORIA
Middle Name:KEATON
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 DREAM AVE
Mailing Address - Street 2:
Mailing Address - City:DELCO
Mailing Address - State:NC
Mailing Address - Zip Code:28436-8700
Mailing Address - Country:US
Mailing Address - Phone:910-655-0698
Mailing Address - Fax:910-655-0611
Practice Address - Street 1:817B S MADISON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-4613
Practice Address - Country:US
Practice Address - Phone:910-207-6761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-21951101YA0400X
NCP010377101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)