Provider Demographics
NPI:1952653172
Name:BERRY, CHASTITY
Entity Type:Individual
Prefix:
First Name:CHASTITY
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 TRIPLETT STREET
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42302-1668
Mailing Address - Country:US
Mailing Address - Phone:270-683-4517
Mailing Address - Fax:
Practice Address - Street 1:815 TRIPLETT STREET
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42302-1668
Practice Address - Country:US
Practice Address - Phone:270-683-4517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4013235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY184517OtherMEDICARE
KY45118379Medicaid