Provider Demographics
NPI:1083433486
Name:BERRY, CHARISSE MICHAEL
Entity type:Individual
Prefix:
First Name:CHARISSE
Middle Name:MICHAEL
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5433 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-3731
Mailing Address - Country:US
Mailing Address - Phone:804-943-5935
Mailing Address - Fax:
Practice Address - Street 1:2400 OLD BRICK RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-5841
Practice Address - Country:US
Practice Address - Phone:804-605-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704013788101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional