Provider Demographics
NPI:1548612823
Name:BERRY, GAGE NATHANIEL (ATC)
Entity Type:Individual
Prefix:MR
First Name:GAGE
Middle Name:NATHANIEL
Last Name:BERRY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 BOXWOOD FARM RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:VA
Mailing Address - Zip Code:24521-4511
Mailing Address - Country:US
Mailing Address - Phone:434-841-1917
Mailing Address - Fax:
Practice Address - Street 1:110 HEISMAN ST
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29634-0001
Practice Address - Country:US
Practice Address - Phone:864-656-3453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer