Provider Demographics
NPI:1083728885
Name:OBRYANT, DALE J (OTR)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:J
Last Name:OBRYANT
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5886 VENTURE PARK
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1848
Mailing Address - Country:US
Mailing Address - Phone:269-375-2200
Mailing Address - Fax:269-375-2266
Practice Address - Street 1:5886 VENTURE PARK
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1848
Practice Address - Country:US
Practice Address - Phone:269-375-2200
Practice Address - Fax:269-375-2266
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000845225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN86580001Medicare ID - Type Unspecified