Healthcare Provider Details

I. General information

NPI: 1730855255
Provider Name (Legal Business Name): KAREN YOSHIMOTO BERRY LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 MONTGOMERY BLVD NE # 5
ALBUQUERQUE NM
87111-2468
US

IV. Provider business mailing address

9201 MONTGOMERY BLVD NE # 5
ALBUQUERQUE NM
87111-2468
US

V. Phone/Fax

Practice location:
  • Phone: 505-217-1717
  • Fax:
Mailing address:
  • Phone: 505-217-1717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCSA0219191
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: