Provider Demographics
NPI:1972623411
Name:BERRY, TIMOTHY D (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:D
Last Name:BERRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:TIM
Other - Middle Name:D
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:800 KENSINGTON AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5670
Mailing Address - Country:US
Mailing Address - Phone:406-830-3808
Mailing Address - Fax:775-243-9945
Practice Address - Street 1:2831 FORT MISSOULA RD STE 106
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7427
Practice Address - Country:US
Practice Address - Phone:406-830-3808
Practice Address - Fax:775-243-9945
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8854178Medicare ID - Type UnspecifiedPSYCHOLOGY