Provider Demographics
NPI:1871707539
Name:BERKLEY, MARA (MFT, PSYD)
Entity type:Individual
Prefix:DR
First Name:MARA
Middle Name:
Last Name:BERKLEY
Suffix:
Gender:F
Credentials:MFT, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 ANGELL ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4414
Mailing Address - Country:US
Mailing Address - Phone:401-529-7861
Mailing Address - Fax:401-455-1771
Practice Address - Street 1:78 ORIOLE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5528
Practice Address - Country:US
Practice Address - Phone:401-529-7861
Practice Address - Fax:401-455-1771
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMFT00097106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist