Provider Demographics
NPI:1588716682
Name:BERRY, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
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 1:8900 N CENTRAL AVE STE 108C
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2869
Mailing Address - Country:US
Mailing Address - Phone:602-748-5200
Mailing Address - Fax:
Practice Address - Street 1:8900 N CENTRAL AVE STE 108C
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2869
Practice Address - Country:US
Practice Address - Phone:602-748-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X, 373H00000X, 171M00000X, 106S00000X
AZ3320482103TS0200X, 101YS0200X
AZLAC-18459101Y00000X
AZLASAC-13294101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No174H00000XOther Service ProvidersHealth Educator
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ033121Medicare ID - Type UnspecifiedAHCCCS