Provider Demographics
NPI:1053061341
Name:BERRY, KRISTOPHER (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-1636
Mailing Address - Country:US
Mailing Address - Phone:937-416-6734
Mailing Address - Fax:
Practice Address - Street 1:47 S VINE ST
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-1636
Practice Address - Country:US
Practice Address - Phone:937-416-6734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10028225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant