Provider Demographics
NPI:1386408748
Name:BERRY, RALPHEAL
Entity type:Individual
Prefix:
First Name:RALPHEAL
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-3416
Mailing Address - Country:US
Mailing Address - Phone:380-223-7219
Mailing Address - Fax:
Practice Address - Street 1:215 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-3416
Practice Address - Country:US
Practice Address - Phone:380-223-7219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator