Provider Demographics
NPI:1851953194
Name:BERRY, MICHAEL L (PTA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:BERRY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6513 BARGE ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-1730
Mailing Address - Country:US
Mailing Address - Phone:509-895-1771
Mailing Address - Fax:
Practice Address - Street 1:6513 BARGE ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-1730
Practice Address - Country:US
Practice Address - Phone:509-895-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160046895225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant