Provider Demographics
NPI:1093006280
Name:BERRY, ESMERALDA VIRGINIA
Entity Type:Individual
Prefix:MS
First Name:ESMERALDA
Middle Name:VIRGINIA
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ESMERALDA
Other - Middle Name:VIRGINIA
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:48303 20TH ST W
Mailing Address - Street 2:SPACE 166
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-7424
Mailing Address - Country:US
Mailing Address - Phone:661-468-0071
Mailing Address - Fax:
Practice Address - Street 1:48303 20TH ST W
Practice Address - Street 2:SPACEW 166
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-7424
Practice Address - Country:US
Practice Address - Phone:800-787-6787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4671225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant