Provider Demographics
NPI:1215144753
Name:BERRY, SALLY (MA, RD, LD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:MA, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5307 W 80TH TER
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-4916
Mailing Address - Country:US
Mailing Address - Phone:913-648-2568
Mailing Address - Fax:913-648-6322
Practice Address - Street 1:8100 MARTY ST STE 115
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204-3737
Practice Address - Country:US
Practice Address - Phone:913-648-2568
Practice Address - Fax:913-648-6322
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS000040133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered