Healthcare Provider Details

I. General information

NPI: 1578153235
Provider Name (Legal Business Name): KECIA MARSHALL BERRY PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7222 CAVENDER DR SW
ATLANTA GA
30331-9526
US

IV. Provider business mailing address

7741 ROSWELL RD
SANDY SPRINGS GA
30350-4845
US

V. Phone/Fax

Practice location:
  • Phone: 404-200-3565
  • Fax:
Mailing address:
  • Phone: 404-612-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number229022
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN229022
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN229022
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: