Provider Demographics
NPI:1073276929
Name:BRYSON, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:BRYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 ALBERT FENTRESS RD
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:TN
Mailing Address - Zip Code:37073-5110
Mailing Address - Country:US
Mailing Address - Phone:615-995-2088
Mailing Address - Fax:
Practice Address - Street 1:608 8TH AVE E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-2910
Practice Address - Country:US
Practice Address - Phone:615-384-8453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000007764225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant