Provider Demographics
NPI:1841701547
Name:BERRY, LISA (LADC 1)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 OCEAN AVE UNIT 610
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1382
Mailing Address - Country:US
Mailing Address - Phone:626-675-4821
Mailing Address - Fax:
Practice Address - Street 1:650 OCEAN AVE UNIT 610
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-1382
Practice Address - Country:US
Practice Address - Phone:626-675-4821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-20
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor