Basic Information
| Provider Information | |||||||||
| NPI: | 1154666485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | YALONDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1831 N EVANSTON PL | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741102815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189241527 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12005 E 470 RD | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740173737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183420770 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2012 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 7147 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 000000000 | 05 | OK | MEDICAID |