Provider Demographics
NPI:1063499648
Name:BERRY, STEPHANIE KROK (PT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:KROK
Last Name:BERRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-2372
Mailing Address - Country:US
Mailing Address - Phone:203-270-0330
Mailing Address - Fax:203-270-0330
Practice Address - Street 1:103 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-2372
Practice Address - Country:US
Practice Address - Phone:203-270-0330
Practice Address - Fax:203-270-0330
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
042751OtherHEALTHNET
CT080001143CT03OtherANTHEM BLUE CROSS & BLUE
221657OtherWELLCARE
Q30Y4OtherEMPIRE BLUE CROSS BLUE SH