Provider Demographics
NPI:1235681255
Name:BERRY, STACEY CAITLYNN
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:CAITLYNN
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:CAITLYNN
Other - Last Name:BRAGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24681 NORTHWESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2305
Mailing Address - Country:US
Mailing Address - Phone:248-231-3731
Mailing Address - Fax:248-779-1819
Practice Address - Street 1:24681 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2305
Practice Address - Country:US
Practice Address - Phone:248-231-3731
Practice Address - Fax:238-779-1819
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician