Healthcare Provider Details

I. General information

NPI: 1902483993
Provider Name (Legal Business Name): PENNIE BERRY MS, LPC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20655 RUSSELL CORNER RD
GRAVETTE AR
72736-8955
US

IV. Provider business mailing address

PO BOX 285
GRAVETTE AR
72736-0285
US

V. Phone/Fax

Practice location:
  • Phone: 479-366-2279
  • Fax:
Mailing address:
  • Phone: 479-366-2279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP2305020
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM2305003
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: