Provider Demographics
NPI:1174851083
Name:O'BERRY, WILLARD DANIEL III (MSPT)
Entity Type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:DANIEL
Last Name:O'BERRY
Suffix:III
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1982 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-1022
Mailing Address - Country:US
Mailing Address - Phone:801-726-6507
Mailing Address - Fax:
Practice Address - Street 1:1982 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-1022
Practice Address - Country:US
Practice Address - Phone:801-726-6507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT314657-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist