Healthcare Provider Details

I. General information

NPI: 1801870290
Provider Name (Legal Business Name): MRS. CHRISTINA BERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINA BERRY MS OTR/L

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 SOUTH ST
SOUTHOLD NY
11971-1996
US

IV. Provider business mailing address

215 SOUTH ST
SOUTHOLD NY
11971-1996
US

V. Phone/Fax

Practice location:
  • Phone: 631-765-8084
  • Fax: 631-765-8897
Mailing address:
  • Phone: 631-765-8084
  • Fax: 631-765-0013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0128821
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: