Healthcare Provider Details

I. General information

NPI: 1083003651
Provider Name (Legal Business Name): KIMBERLY BERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4260 BUCKSKIN LAKE DR
ELLICOTT CITY MD
21042-1254
US

IV. Provider business mailing address

4260 BUCKSKIN LAKE DR
ELLICOTT CITY MD
21042-1254
US

V. Phone/Fax

Practice location:
  • Phone: 443-820-8934
  • Fax:
Mailing address:
  • Phone: 443-820-8934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberA00636
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: