Provider Demographics
NPI:1790977148
Name:BERRY, SHAWN MICHAEL
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:MICHAEL
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 1:505 Q ST
Mailing Address - Street 2:HERITAGE OF BRIDGEPORT
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NE
Mailing Address - Zip Code:69336-0081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 Q ST
Practice Address - Street 2:HERITAGE OF BRIDGEPORT
Practice Address - City:BRIDGEPORT
Practice Address - State:NE
Practice Address - Zip Code:69336-0081
Practice Address - Country:US
Practice Address - Phone:308-262-1823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE751225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant