Provider Demographics
NPI:1144575424
Name:BERRY, LANCE (PT)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30126 DIAMOND DOVE TRL
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-3724
Mailing Address - Country:US
Mailing Address - Phone:512-925-8857
Mailing Address - Fax:
Practice Address - Street 1:3621 E WHITESTONE BLVD # 400
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-6998
Practice Address - Country:US
Practice Address - Phone:512-925-8857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12205372251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic