Provider Demographics
NPI:1477904431
Name:BERRY, ALICIA (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 S SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-2125
Mailing Address - Country:US
Mailing Address - Phone:918-527-0415
Mailing Address - Fax:
Practice Address - Street 1:3905 S HUDSON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5607
Practice Address - Country:US
Practice Address - Phone:918-627-3390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer