Provider Demographics
NPI:1366534877
Name:BERRY, AMANDA J (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:BERRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6332 W IRMA LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6609
Mailing Address - Country:US
Mailing Address - Phone:630-309-0279
Mailing Address - Fax:
Practice Address - Street 1:6332 W IRMA LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6609
Practice Address - Country:US
Practice Address - Phone:630-309-0279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-033567225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK25020Medicare PIN
IL202845137Medicare PIN