MEDICARE: MERISSA BERNS-GRAY DPT

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	225100000X	Physical Therapist	070.020063	IL

General Provider Information

NPI Number	:	1073969028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MERISSA BERNS-GRAY DPT

Provider Business Mailing Address
First Line	:	650 N KINZIE AVE
Second Line	:
City	:	BRADLEY
State	:	IL
Zip	:	60915-1227
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 N KINZIE AVE
Second Line	:
City	:	BRADLEY
State	:	IL
Zip	:	60915-1227
Country	:	US
Telephone Number	:	815-933-1666
Fax Number	:

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

Provider Enumeration Date	:	05/09/2016
Last Update Date	:	05/09/2016

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