Provider Demographics
NPI:1124035381
Name:KELLY-BERRY, TERESA ALICE (PT)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:ALICE
Last Name:KELLY-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 1:250 WAMPANOAG TRL
Mailing Address - Street 2:SUITE301
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-2218
Mailing Address - Country:US
Mailing Address - Phone:401-451-1234
Mailing Address - Fax:
Practice Address - Street 1:250 WAMPANOAG TRL
Practice Address - Street 2:SUITE301
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2218
Practice Address - Country:US
Practice Address - Phone:401-451-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT00638174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist