Provider Demographics
NPI:1336815695
Name:BERRY, TIMOTHY DAVID (LMHC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DAVID
Last Name:BERRY
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 ATLANTIC BLVD # 235
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3313
Mailing Address - Country:US
Mailing Address - Phone:904-527-5202
Mailing Address - Fax:
Practice Address - Street 1:13300 ATLANTIC BLVD APT 924
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6137
Practice Address - Country:US
Practice Address - Phone:904-527-5202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH19286101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health