Provider Demographics
NPI:1790187953
Name:BERRY, QUINN
Entity type:Individual
Prefix:
First Name:QUINN
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-0268
Mailing Address - Country:US
Mailing Address - Phone:319-331-7518
Mailing Address - Fax:
Practice Address - Street 1:207 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1203
Practice Address - Country:US
Practice Address - Phone:319-331-7518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001423101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health