Provider Demographics
NPI:1043570963
Name:BERRY, LEANNE MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:MARIE
Last Name:BERRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-2571
Mailing Address - Country:US
Mailing Address - Phone:573-406-5019
Mailing Address - Fax:
Practice Address - Street 1:1734 MARKET ST
Practice Address - Street 2:THERAPY DEPT
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-4025
Practice Address - Country:US
Practice Address - Phone:573-629-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011034561225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant