Provider Demographics
NPI:1194467217
Name:BERRY, ALTHEA
Entity type:Individual
Prefix:
First Name:ALTHEA
Middle Name:
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 1:8743 W PINE VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-0020
Mailing Address - Country:US
Mailing Address - Phone:715-853-2884
Mailing Address - Fax:
Practice Address - Street 1:1905 S TOPAZ WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4477
Practice Address - Country:US
Practice Address - Phone:208-518-0870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-09
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician