Healthcare Provider Details

I. General information

NPI: 1104747112
Provider Name (Legal Business Name): ALICE COSTA BERRY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10310 THE GROVE BLVD
BATON ROUGE LA
70836-6455
US

IV. Provider business mailing address

10720 LINKWOOD CT APT 527
BATON ROUGE LA
70810-2942
US

V. Phone/Fax

Practice location:
  • Phone: 225-761-5200
  • Fax:
Mailing address:
  • Phone: 985-788-3590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number19807
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: