Provider Demographics
NPI:1023890357
Name:BERRY, MELLISA S (LSW)
Entity type:Individual
Prefix:
First Name:MELLISA
Middle Name:S
Last Name:BERRY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 MAIN ST APT D
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-1433
Mailing Address - Country:US
Mailing Address - Phone:862-571-9349
Mailing Address - Fax:
Practice Address - Street 1:1401 VALLEY ROAD SUITE 303
Practice Address - Street 2:SUITE. 303
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470
Practice Address - Country:US
Practice Address - Phone:201-320-6334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06974500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker