Provider Demographics
NPI:1528795689
Name:BERRY, GABRIELLE (PPC)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 OVERTHRUST RD
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-9260
Mailing Address - Country:US
Mailing Address - Phone:307-789-4224
Mailing Address - Fax:
Practice Address - Street 1:190 OVERTHRUST RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9260
Practice Address - Country:US
Practice Address - Phone:307-789-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WY1509101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health