Provider Demographics
NPI:1942927694
Name:NETTIE MAE BERRY FOUNDATION LLC
Entity Type:Organization
Organization Name:NETTIE MAE BERRY FOUNDATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TANDRA
Authorized Official - Middle Name:LAMIKIA
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-258-3450
Mailing Address - Street 1:PO BOX 358774
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32635-8774
Mailing Address - Country:US
Mailing Address - Phone:352-258-3450
Mailing Address - Fax:352-379-5502
Practice Address - Street 1:901 NW 8TH AVE STE A2
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-5000
Practice Address - Country:US
Practice Address - Phone:352-258-3450
Practice Address - Fax:352-379-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services