Provider Demographics
NPI:1073655452
Name:RYAN, BRENNAN KELLEY (PT)
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:KELLEY
Last Name:RYAN
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 1:1515 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4603
Mailing Address - Country:US
Mailing Address - Phone:312-550-5436
Mailing Address - Fax:
Practice Address - Street 1:2008 GROVE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-4534
Practice Address - Country:US
Practice Address - Phone:312-550-5436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206096225100000X
IL070015538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist