Provider Demographics
NPI:1902483993
Name:BERRY, PENNIE (MS, LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:PENNIE
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:MS, LPC, LMFT
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 285
Mailing Address - Street 2:
Mailing Address - City:GRAVETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72736-0285
Mailing Address - Country:US
Mailing Address - Phone:479-366-2279
Mailing Address - Fax:
Practice Address - Street 1:20655 RUSSELL CORNER RD
Practice Address - Street 2:
Practice Address - City:GRAVETTE
Practice Address - State:AR
Practice Address - Zip Code:72736-8955
Practice Address - Country:US
Practice Address - Phone:479-366-2279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARM2305003106H00000X
ARP2305020101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist