Provider Demographics
NPI:1184873804
Name:BERRY, PRESTON EUGENE (IADC & CRADC)
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:EUGENE
Last Name:BERRY
Suffix:
Gender:M
Credentials:IADC & CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 S. FAIRMONT STREET
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52802-5351
Mailing Address - Country:US
Mailing Address - Phone:563-322-2667
Mailing Address - Fax:563-322-3671
Practice Address - Street 1:1523 S. FAIRMONT STREET
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52802-5351
Practice Address - Country:US
Practice Address - Phone:563-322-2667
Practice Address - Fax:563-322-3671
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7544101YA0400X
TX11618-1121101YA0400X
IL37377101YA0400X
IA21R028101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11618-1121OtherICADC
TX7544OtherTEXAS DEPARTMENT OF STATE HEALTH SERVICES
IA21R028OtherIADC
IL37377OtherCRADC