Healthcare Provider Details

I. General information

NPI: 1336098672
Provider Name (Legal Business Name): EUGENE NATHANIEL BERRY MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2026
Last Update Date: 01/28/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 TERESA CT SE
RIO RANCHO NM
87124-2382
US

IV. Provider business mailing address

1039 9TH AVE
HONOLULU HI
96816-2417
US

V. Phone/Fax

Practice location:
  • Phone: 505-688-7083
  • Fax:
Mailing address:
  • Phone: 334-430-8198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2026-0080
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: