Provider Demographics
NPI:1831280767
Name:BERRY, DAVID RAY (MSHR/ICAADC/LADC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:RAY
Last Name:BERRY
Suffix:
Gender:M
Credentials:MSHR/ICAADC/LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23685 S 472 RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1548
Mailing Address - Country:US
Mailing Address - Phone:918-458-0179
Mailing Address - Fax:918-577-3270
Practice Address - Street 1:1011 HONOR HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-1318
Practice Address - Country:US
Practice Address - Phone:918-577-3039
Practice Address - Fax:918-577-3270
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK353101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)