MEDICARE: AMANDA LAUREN BERRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	166.001099	IL

General Provider Information

NPI Number	:	1205379484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA LAUREN BERRY

Provider Business Mailing Address
First Line	:	1236 W WEBSTER AVE # 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-3140
Country	:	US
Telephone Number	:	312-714-5168
Fax Number	:

Provider Business Practice Location Address
First Line	:	1967 N DAYTON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-5030
Country	:	US
Telephone Number	:	312-714-5168
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2016
Last Update Date	:	05/13/2019

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Directions to “ AMANDA LAUREN BERRY ” Practice Location

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