Basic Information
Provider Information | |||||||||
NPI: | 1609813633 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERRY | ||||||||
FirstName: | CHRISTINA | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPCC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40722 STATE ROUTE 154 | ||||||||
Address2: |   | ||||||||
City: | LISBON | ||||||||
State: | OH | ||||||||
PostalCode: | 444328500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304249573 | ||||||||
FaxNumber: | 3304247140 | ||||||||
Practice Location | |||||||||
Address1: | 166 1/2 VINE ST | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | OH | ||||||||
PostalCode: | 444602939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3303321514 | ||||||||
FaxNumber: | 3303324938 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2006 | ||||||||
LastUpdateDate: | 05/09/2019 | ||||||||
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 | 101Y00000X | C 0500699 | OH | N |   | Behavioral Health & Social Service Providers | Counselor |   | 101Y00000X | E0500699 | OH | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
No ID Information.