=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952182735
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW BERRY M.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2023
-----------------------------------------------------
Last Update Date | 10/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2018 EXETER RD
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38138-3945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-756-4499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2583 EVERETT AVE
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38112-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-461-2841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 349
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------