Provider Demographics
NPI:1124699699
Name:HARRELL-BERRY, ANTONIQUE M
Entity type:Individual
Prefix:
First Name:ANTONIQUE
Middle Name:M
Last Name:HARRELL-BERRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19251 MACK AVE STE M450
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2893
Mailing Address - Country:US
Mailing Address - Phone:313-343-1370
Mailing Address - Fax:248-712-4831
Practice Address - Street 1:19251 MACK AVE STE M450
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2893
Practice Address - Country:US
Practice Address - Phone:313-343-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician