Healthcare Provider Details

I. General information

NPI: 1699191304
Provider Name (Legal Business Name): DOUGLAS B BERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4816 S 78TH EAST PL APT 91-109
TULSA OK
74145-6690
US

IV. Provider business mailing address

4816 S 78TH EAST PL APT 91-109
TULSA OK
74145-6690
US

V. Phone/Fax

Practice location:
  • Phone: 870-310-3850
  • Fax: 888-875-1829
Mailing address:
  • Phone: 870-310-3850
  • Fax: 888-875-1829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: