Provider Demographics
NPI:1578084786
Name:BERRY, BRIAN R
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3388 FALCON CREST DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-3174
Mailing Address - Country:US
Mailing Address - Phone:660-853-0023
Mailing Address - Fax:
Practice Address - Street 1:107 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:HUNNEWELL
Practice Address - State:MO
Practice Address - Zip Code:63443-3051
Practice Address - Country:US
Practice Address - Phone:660-853-0023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016020955225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty