Basic Information
| Provider Information | |||||||||
| NPI: | 1831127075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | FAITH | ||||||||
| MiddleName: | JOANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOOR | ||||||||
| OtherFirstName: | FAITH JOANN | ||||||||
| OtherMiddleName: | JOANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4253 N CROSSOVER RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795215731 | ||||||||
| FaxNumber: | 4795214926 | ||||||||
| Practice Location | |||||||||
| Address1: | 4253 N CROSSOVER RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794436496 | ||||||||
| FaxNumber: | 4795214926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A0308072 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.