=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053443168
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYN MARIE BERRY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6931 VAN NUYS BLVD 2ND FLOOR
-----------------------------------------------------
City | VAN NUYS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91405-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-909-5870
-----------------------------------------------------
Fax | 818-909-9980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4733 HASKELL AVE #48
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-1616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-986-2123
-----------------------------------------------------
Fax | 818-986-2123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC28911
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------