Basic Information
| Provider Information | |||||||||
| NPI: | 1053479493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | PERCITA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CAADE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERRY | ||||||||
| OtherFirstName: | SUE | ||||||||
| OtherMiddleName: | P | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CAADE | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 592 RIO LINDO AVE | ||||||||
| Address2: | |||||||||
| City: | CHICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959261817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308912951 | ||||||||
| FaxNumber: | 5308956547 | ||||||||
| Practice Location | |||||||||
| Address1: | 592 RIO LINDO AVENUE | ||||||||
| Address2: | |||||||||
| City: | CHICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308912775 | ||||||||
| FaxNumber: | 5308956547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 10/05/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 990328 | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.