Provider Demographics
NPI:1730514514
Name:BERRY, MATTHEW G
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:G
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48216-1439
Mailing Address - Country:US
Mailing Address - Phone:248-787-0627
Mailing Address - Fax:
Practice Address - Street 1:542 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-1439
Practice Address - Country:US
Practice Address - Phone:248-787-0627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist