MEDICARE: MICHELLE BERRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service

General Provider Information

NPI Number	:	1023559572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE BERRY

Provider Business Mailing Address
First Line	:	532 N BRYANT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-1771
Country	:	US
Telephone Number	:	971-344-7968
Fax Number	:

Provider Business Practice Location Address
First Line	:	532 N BRYANT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-1771
Country	:	US
Telephone Number	:	971-344-7968
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2017
Last Update Date	:	03/16/2017

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Directions to “ MICHELLE BERRY ” Practice Location

Language	Start Address	Practice Location

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