1669503843 NPI number — DR. LEANDRA NICOLE BERRY PH.D.

Table of content: DR. LEANDRA NICOLE BERRY PH.D. (NPI 1669503843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669503843 NPI number — DR. LEANDRA NICOLE BERRY PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERRY
Provider First Name:
LEANDRA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
LEANDRA
Provider Other Middle Name:
BERRY
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669503843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6701 FANNIN ST
Provider Second Line Business Mailing Address:
SUITE 1630
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77030-2608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-822-3926
Provider Business Mailing Address Fax Number:
832-825-4164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6701 FANNIN ST
Provider Second Line Business Practice Location Address:
SUITE 1630
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77030-2608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-822-3926
Provider Business Practice Location Address Fax Number:
832-825-4164
Provider Enumeration Date:
03/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X , with the licence number:  PS017038 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103G00000X , with the licence number: PS017038 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TM1800X , with the licence number: PS017038 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)