Healthcare Provider Details

I. General information

NPI: 1205457512
Provider Name (Legal Business Name): COURTNEY BERRY LSGW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6031 N HIL MAR CIR
DISTRICT HEIGHTS MD
20747-2962
US

IV. Provider business mailing address

6031 N HIL MAR CIR
DISTRICT HEIGHTS MD
20747-2962
US

V. Phone/Fax

Practice location:
  • Phone: 240-281-2283
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: