Provider Demographics
NPI:1083134225
Name:BERRY, MATTHEW THOMAS (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BERRY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28819 PUJOL ST APT 112
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-6703
Mailing Address - Country:US
Mailing Address - Phone:909-915-5704
Mailing Address - Fax:
Practice Address - Street 1:41278 MARGARITA RD STE 102
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5579
Practice Address - Country:US
Practice Address - Phone:951-587-8105
Practice Address - Fax:951-587-8405
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5274225100000X
CA296781225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist