Provider Demographics
NPI:1346451986
Name:BERRY, ANGELA D (PT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:D
Last Name:BERRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:ANGELA
Other - Middle Name:D
Other - Last Name:BRUMFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5409 TIFFANY DR
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1033
Mailing Address - Country:US
Mailing Address - Phone:304-776-2706
Mailing Address - Fax:
Practice Address - Street 1:4605 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1311
Practice Address - Country:US
Practice Address - Phone:304-766-3589
Practice Address - Fax:304-766-3793
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1572225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2129415OtherMAMSI OPTIMUM CHOICE