Provider Demographics
NPI:1942744768
Name:BERRY, NILES ALEXANDER (LLBSW)
Entity Type:Individual
Prefix:MR
First Name:NILES
Middle Name:ALEXANDER
Last Name:BERRY
Suffix:
Gender:M
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 TOWNER ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5723
Mailing Address - Country:US
Mailing Address - Phone:734-544-3050
Mailing Address - Fax:734-544-6732
Practice Address - Street 1:555 TOWNER ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198
Practice Address - Country:US
Practice Address - Phone:734-544-3050
Practice Address - Fax:734-544-6732
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802089332104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker