Provider Demographics
NPI:1942498266
Name:BERRY, MICHELLE P (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:P
Last Name:BERRY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6205 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1517
Mailing Address - Country:US
Mailing Address - Phone:260-385-2130
Mailing Address - Fax:260-818-2044
Practice Address - Street 1:6205 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1517
Practice Address - Country:US
Practice Address - Phone:260-385-2130
Practice Address - Fax:260-818-2044
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000293A174400000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200628720AMedicaid