Healthcare Provider Details

I. General information

NPI: 1013566736
Provider Name (Legal Business Name): MATTHEW ALLAN BERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14677 MERRILL AVE
FONTANA CA
92335
US

IV. Provider business mailing address

9800 MESA LINDA ST APT 178
HESPERIA CA
92345-0105
US

V. Phone/Fax

Practice location:
  • Phone: 951-643-2335
  • Fax:
Mailing address:
  • Phone: 909-539-3040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number34542
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: