Provider Demographics
NPI:1972716512
Name:BERRY, RUSSELL D (LPTA)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:D
Last Name:BERRY
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 104
Mailing Address - Street 2:
Mailing Address - City:GRANITE
Mailing Address - State:OK
Mailing Address - Zip Code:73547-0104
Mailing Address - Country:US
Mailing Address - Phone:580-535-4581
Mailing Address - Fax:
Practice Address - Street 1:1 WICKERSHAM ST
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-9117
Practice Address - Country:US
Practice Address - Phone:580-782-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK812225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant