Provider Demographics
NPI:1669286951
Name:BERRY, CLYDE DANIEL
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:DANIEL
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 SW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-4700
Mailing Address - Country:US
Mailing Address - Phone:360-740-3534
Mailing Address - Fax:
Practice Address - Street 1:375 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-4700
Practice Address - Country:US
Practice Address - Phone:360-740-3534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60248171101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)