Basic Information
| Provider Information | |||||||||
| NPI: | 1588859508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2033 BARBADOS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158352103 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15620 MCGREGOR BLVD STE 115 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339082528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394546262 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2007 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 6045 | MN | N | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | 6045 | MN | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231H00000X | AY2103 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.