Provider Demographics
NPI:1740625128
Name:BERTA, CARRIE L (PSYD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:BERTA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 EASTWAY DR
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44242-0001
Mailing Address - Country:US
Mailing Address - Phone:330-672-8194
Mailing Address - Fax:330-672-2272
Practice Address - Street 1:1500 EASTWAY DR
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44242-0001
Practice Address - Country:US
Practice Address - Phone:330-672-8194
Practice Address - Fax:330-672-2272
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6918103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist