MEDICARE: MRS. TERESSA KAY BERRY LCSW, RPT

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	1041C0700X	Clinical Social Worker	2017004507	MO

General Provider Information

NPI Number	:	1790141042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERESSA KAY BERRY LCSW, RPT

Provider Business Mailing Address
First Line	:	5065 N MAIN ST
Second Line	:
City	:	JOPLIN
State	:	MO
Zip	:	64801-7821
Country	:	US
Telephone Number	:	417-355-3278
Fax Number	:

Provider Business Practice Location Address
First Line	:	5065 N MAIN ST
Second Line	:
City	:	JOPLIN
State	:	MO
Zip	:	64801-7821
Country	:	US
Telephone Number	:	417-355-3278
Fax Number	:

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

Provider Enumeration Date	:	01/01/2016
Last Update Date	:	10/01/2024

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