Provider Demographics
NPI:1508194218
Name:BERRY, AMIE M (LCSW)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:M
Last Name:BERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMIE
Other - Middle Name:
Other - Last Name:THOMAS, LCSW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:13820 OLD ST. AUGUSTINE ROAD
Mailing Address - Street 2:SUITE 113-166
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5506
Mailing Address - Country:US
Mailing Address - Phone:904-748-9106
Mailing Address - Fax:888-247-7481
Practice Address - Street 1:4651 SALISBURY ROAD SOUTH
Practice Address - Street 2:4TH FLOOR, SUITE 428
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5506
Practice Address - Country:US
Practice Address - Phone:904-748-9106
Practice Address - Fax:888-244-7481
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW93521041C0700X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004222300Medicaid