Provider Demographics
NPI:1871645564
Name:BERRY, MILLY ANNE (SLP)
Entity Type:Individual
Prefix:
First Name:MILLY
Middle Name:ANNE
Last Name:BERRY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3645
Mailing Address - Country:US
Mailing Address - Phone:501-664-8022
Mailing Address - Fax:501-850-8788
Practice Address - Street 1:5 REMINGTON DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-8202
Practice Address - Country:US
Practice Address - Phone:501-850-8788
Practice Address - Fax:501-850-8791
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1366235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143779721Medicaid