Provider Demographics
NPI:1326093279
Name:BERKSHIRE, TERRI LAKE (MS PT)
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:LAKE
Last Name:BERKSHIRE
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 MUSEUM ROAD SUITE 104
Mailing Address - Street 2:CONWAY THERAPY SERVICES
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032
Mailing Address - Country:US
Mailing Address - Phone:501-329-3804
Mailing Address - Fax:801-329-0718
Practice Address - Street 1:1500 MUSEUM ROAD SUITE 104
Practice Address - Street 2:CONWAY THERAPY SERVICES
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032
Practice Address - Country:US
Practice Address - Phone:501-329-3804
Practice Address - Fax:801-329-0718
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2472225100000X
VA2305203594225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142131721Medicaid
VA009238P68Medicare ID - Type Unspecified