Provider Demographics
NPI:1659358315
Name:BERRY, PETER R
Entity Type:Individual
Prefix:MR
First Name:PETER
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 1:3600 FM 2181
Mailing Address - Street 2:#300
Mailing Address - City:HICKORY CREEK
Mailing Address - State:TX
Mailing Address - Zip Code:75065-7636
Mailing Address - Country:US
Mailing Address - Phone:940-321-1311
Mailing Address - Fax:940-497-1374
Practice Address - Street 1:1017 EAST TRINITY MILLS RD.
Practice Address - Street 2:STE. 120
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-1458
Practice Address - Country:US
Practice Address - Phone:972-466-0528
Practice Address - Fax:972-466-2345
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20246237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177663501Medicaid
00W653Medicare PIN