Provider Demographics
NPI:1982651972
Name:BERRY, GEORGE WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WILLIAM
Last Name:BERRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E PUGH DR
Mailing Address - Street 2:SUITE 14
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3942
Mailing Address - Country:US
Mailing Address - Phone:812-235-3738
Mailing Address - Fax:
Practice Address - Street 1:1400 E PUGH DR
Practice Address - Street 2:SUITE 14
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3942
Practice Address - Country:US
Practice Address - Phone:812-235-3738
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040577103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INBE-858350Medicare ID - Type UnspecifiedPROVIDER NUMBER