Provider Demographics
NPI:1861715625
Name:BERRY, LAURA (MA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-378-8367
Practice Address - Street 1:11370 N STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-6368
Practice Address - Country:US
Practice Address - Phone:812-339-1691
Practice Address - Fax:812-378-8367
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor