Provider Demographics
NPI:1205357001
Name:BERRY, MOLLY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:343 WINDING WOODS CTR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366
Practice Address - Country:US
Practice Address - Phone:636-439-2004
Practice Address - Fax:636-439-2054
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13101225100000X
MO2018045090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ13101OtherLICENSE