Basic Information
| Provider Information | |||||||||
| NPI: | 1740412873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 270 FARMINGTON AVE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060321909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604094595 | ||||||||
| FaxNumber: | 8604094860 | ||||||||
| Practice Location | |||||||||
| Address1: | 385 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | GUILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064376003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034532844 | ||||||||
| FaxNumber: | 2034538772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2009 | ||||||||
| LastUpdateDate: | 09/27/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT24938 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 8914 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT-24938 | 01 | FL | FL. PHYSICAL THERAPIST LICENSE NUMBER | OTHER | 8914 | 01 | CT | CT LICENSE NUMBER | OTHER |