Provider Demographics
NPI:1346660388
Name:BERRY, MICHAEL (LCMFT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:LCMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11940 W CENTRAL AVE STE 118
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-5180
Mailing Address - Country:US
Mailing Address - Phone:316-302-5462
Mailing Address - Fax:
Practice Address - Street 1:11940 W CENTRAL AVE STE 118
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-5180
Practice Address - Country:US
Practice Address - Phone:316-302-5462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2845106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist