Healthcare Provider Details

I. General information

NPI: 1699422527
Provider Name (Legal Business Name): CRYSTAL H BERRY & CANDACE S BERRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 OLLIE RD
PELION SC
29123-9400
US

IV. Provider business mailing address

548 OLLIE RD
PELION SC
29123-9400
US

V. Phone/Fax

Practice location:
  • Phone: 803-580-0298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL BERRY
Title or Position: PROVIDER
Credential: MA, NCC
Phone: 803-580-0298