=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972623411
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY D. BERRY PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 10/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2831 FORT MISSOULA RD STE 106
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59804-7427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-830-3808
-----------------------------------------------------
Fax | 775-243-9945
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 KENSINGTON AVE STE 208
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-5670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-830-3808
-----------------------------------------------------
Fax | 775-243-9945
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------