Provider Demographics
NPI:1982777611
Name:BERRY, KEVIN B (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
Last Name:BERRY
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 PARK DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-6573
Mailing Address - Country:US
Mailing Address - Phone:575-317-8099
Mailing Address - Fax:
Practice Address - Street 1:4202 W MCGAFFEY ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-9384
Practice Address - Country:US
Practice Address - Phone:575-623-6749
Practice Address - Fax:575-623-1322
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0084641106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist