Provider Demographics
NPI:1669726741
Name:BERRY, ANGIE (LMFT)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5149 S 1500 W
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-3926
Mailing Address - Country:US
Mailing Address - Phone:801-475-0402
Mailing Address - Fax:801-475-7464
Practice Address - Street 1:5149 S 1500 W
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-3926
Practice Address - Country:US
Practice Address - Phone:801-475-0402
Practice Address - Fax:801-475-7464
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT341397-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist