Provider Demographics
NPI:1033530845
Name:BERRY, ANGELIC (MED, MS)
Entity Type:Individual
Prefix:MRS
First Name:ANGELIC
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:MED, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4732 PATRIOTS DR
Mailing Address - Street 2:
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225-1197
Mailing Address - Country:US
Mailing Address - Phone:618-746-4738
Mailing Address - Fax:
Practice Address - Street 1:4732 PATRIOTS DR
Practice Address - Street 2:
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-1197
Practice Address - Country:US
Practice Address - Phone:618-746-4738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010486235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL934010OtherILLINOIS STATE BOARD OF EDUCATION