Provider Demographics
NPI:1932634391
Name:BERRYMAN, MARY JEANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:JEANNE
Last Name:BERRYMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JEANNE
Other - Last Name:NEWBERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2715 LILAC ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3526
Mailing Address - Country:US
Mailing Address - Phone:360-575-7580
Mailing Address - Fax:
Practice Address - Street 1:2715 LILAC ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3526
Practice Address - Country:US
Practice Address - Phone:360-575-7580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA506039G103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool