Provider Demographics
NPI:1588770572
Name:BERRY, ROBERT A (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:BERRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4265
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86340-4265
Mailing Address - Country:US
Mailing Address - Phone:312-719-6789
Mailing Address - Fax:928-554-4166
Practice Address - Street 1:2860 HOPI DRVE, SUITE 2B
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336
Practice Address - Country:US
Practice Address - Phone:312-719-6789
Practice Address - Fax:928-554-4166
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003335103TC0700X
AZ1987103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL35193OtherNATIONAL REGISTER
IL0001673028OtherBCBS PROVIDER#
IL787490Medicare ID - Type Unspecified