Provider Demographics
NPI:1912547795
Name:BERRY, MARY KATRINA (COMS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATRINA
Last Name:BERRY
Suffix:
Gender:F
Credentials:COMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 SWAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:NORTONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42442-9771
Mailing Address - Country:US
Mailing Address - Phone:270-836-9548
Mailing Address - Fax:
Practice Address - Street 1:145 SWAN LAKE RD
Practice Address - Street 2:
Practice Address - City:NORTONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42442-9771
Practice Address - Country:US
Practice Address - Phone:270-836-9548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5720225CX0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider