Provider Demographics
NPI:1083095608
Name:PHILLIPS, BRYAN MICHAEL (LMT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:MICHAEL
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 SAXON BLVD
Mailing Address - Street 2:STE 301
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-5876
Mailing Address - Country:US
Mailing Address - Phone:386-851-0901
Mailing Address - Fax:
Practice Address - Street 1:1565 SAXON BLVD
Practice Address - Street 2:STE 301
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-5876
Practice Address - Country:US
Practice Address - Phone:386-851-0901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA74126225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist