Provider Demographics
NPI:1255341624
Name:BERRY, EMILY REBECCA (CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:REBECCA
Last Name:BERRY
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 PATRIOT WAY UNIT D
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-2753
Mailing Address - Country:US
Mailing Address - Phone:336-312-6221
Mailing Address - Fax:336-510-0584
Practice Address - Street 1:3201 W MARKET ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1455
Practice Address - Country:US
Practice Address - Phone:336-508-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4611235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC740236BMedicaid