MEDICARE: LISHA BERRY BSW

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	104100000X	Social Worker	6802088254	MI
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1578954632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISHA BERRY BSW

Provider Business Mailing Address
First Line	:	2013 EASTCASTLE DR SE STE B
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-8873
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2013 EASTCASTLE DR SE STE B
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-8873
Country	:	US
Telephone Number	:	616-888-1120
Fax Number	:

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

Provider Enumeration Date	:	02/11/2015
Last Update Date	:	09/02/2025

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