Provider Demographics
NPI:1922523018
Name:BERRY, VICTORIA LEE (MSOT)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LEE
Last Name:BERRY
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LEE
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOT
Mailing Address - Street 1:26 RACETRACK RD NW
Mailing Address - Street 2:STE E
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1640
Mailing Address - Country:US
Mailing Address - Phone:850-543-2163
Mailing Address - Fax:
Practice Address - Street 1:26 E RACETRACK ROAD NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-543-2163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
FLOT18671225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT18671OtherFLORIDA DEPARTMENT OF HEALTH