MEDICARE: DOUGLAS B 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	103K00000X	Behavior Analyst
2	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1699191304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS B BERRY

Provider Business Mailing Address
First Line	:	4816 S 78TH EAST PL
Second Line	:	APT 91-109
City	:	TULSA
State	:	OK
Zip	:	74145-6690
Country	:	US
Telephone Number	:	870-310-3850
Fax Number	:	888-875-1829

Provider Business Practice Location Address
First Line	:	4816 S 78TH EAST PL
Second Line	:	APT 91-109
City	:	TULSA
State	:	OK
Zip	:	74145-6690
Country	:	US
Telephone Number	:	870-310-3850
Fax Number	:	888-875-1829

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

Provider Enumeration Date	:	03/06/2014
Last Update Date	:	03/06/2014

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Directions to “ DOUGLAS B BERRY ” Practice Location

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