Healthcare Provider Details

I. General information

NPI: 1578029906
Provider Name (Legal Business Name): DEBORAH G BERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 OLD RANCH ROAD
TYRONE NM
88065
US

IV. Provider business mailing address

PO BOX 523
TYRONE NM
88065-0523
US

V. Phone/Fax

Practice location:
  • Phone: 575-590-7752
  • Fax:
Mailing address:
  • Phone: 575-590-7752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMHO148821
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: