Provider Demographics
NPI:1790141042
Name:BERRY, TERESSA KAY (LCSW, RPT)
Entity type:Individual
Prefix:MRS
First Name:TERESSA
Middle Name:KAY
Last Name:BERRY
Suffix:
Gender:F
Credentials:LCSW, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5065 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-7821
Mailing Address - Country:US
Mailing Address - Phone:417-355-3278
Mailing Address - Fax:
Practice Address - Street 1:5065 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-7821
Practice Address - Country:US
Practice Address - Phone:417-355-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170045071041C0700X
KS4419104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker