Provider Demographics
NPI:1063919488
Name:BERRY, KATHLEEN CHARISE (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:CHARISE
Last Name:BERRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28514
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-0514
Mailing Address - Country:US
Mailing Address - Phone:760-792-3849
Mailing Address - Fax:
Practice Address - Street 1:707 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-6160
Practice Address - Country:US
Practice Address - Phone:760-294-1206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-47451106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician