Provider Demographics
NPI:1063691178
Name:BERRON, ERNESTINE
Entity type:Individual
Prefix:
First Name:ERNESTINE
Middle Name:
Last Name:BERRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALBERT
Other - Middle Name:
Other - Last Name:BERRON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1533 W GRANT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-3313
Mailing Address - Country:US
Mailing Address - Phone:602-258-6806
Mailing Address - Fax:
Practice Address - Street 1:1533 W GRANT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-3313
Practice Address - Country:US
Practice Address - Phone:602-258-6806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8506385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child