Provider Demographics
NPI:1891004123
Name:BERRY, KELLY (MSPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ARCHBALD
Mailing Address - State:PA
Mailing Address - Zip Code:18403-1822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1086 HIGHWAY 315 BLVD # 315
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18702-7012
Practice Address - Country:US
Practice Address - Phone:570-823-7761
Practice Address - Fax:570-829-7761
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT020886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist