Healthcare Provider Details

I. General information

NPI: 1235778374
Provider Name (Legal Business Name): CARISSA NICOLE BERRY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. CARISSA NICOLE CLIFTON

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2489 WENDELL BLVD
WENDELL NC
27591-6903
US

IV. Provider business mailing address

2489 WENDELL BLVD
WENDELL NC
27591-6903
US

V. Phone/Fax

Practice location:
  • Phone: 919-792-0835
  • Fax: 919-792-0835
Mailing address:
  • Phone: 919-792-0835
  • Fax: 919-792-0835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC018307
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberPO14138
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPO14138
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: