Provider Demographics
NPI:1073777256
Name:BRYANT, TINA (PT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BRYANT
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 1:410 FALCON CRST
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-7818
Mailing Address - Country:US
Mailing Address - Phone:502-551-7645
Mailing Address - Fax:502-538-9254
Practice Address - Street 1:410 FALCON CRST
Practice Address - Street 2:
Practice Address - City:MOUNT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-7818
Practice Address - Country:US
Practice Address - Phone:502-551-7645
Practice Address - Fax:502-538-9254
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002042225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics