Provider Demographics
NPI:1508642315
Name:BERRY, TANYA (R1516360723)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:R1516360723
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 VINE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-1612
Mailing Address - Country:US
Mailing Address - Phone:323-769-6100
Mailing Address - Fax:
Practice Address - Street 1:1224 VINE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-1612
Practice Address - Country:US
Practice Address - Phone:323-769-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA1516360723225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)