Healthcare Provider Details

I. General information

NPI: 1851584726
Provider Name (Legal Business Name): ELISABETH M BERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 FISH CREEK THOROUGHFARE
MONTGOMERY TX
77316-6965
US

IV. Provider business mailing address

107 N CONCORD VALLEY CIR
SPRING TX
77382-1390
US

V. Phone/Fax

Practice location:
  • Phone: 936-272-0790
  • Fax:
Mailing address:
  • Phone: 937-344-9549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number1111342
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number007742
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number61470
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: