Provider Demographics
NPI:1104196724
Name:BRYAN, ELIZABETH RENEE (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:RENEE
Last Name:BRYAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 S. 13TH STREET
Mailing Address - Street 2:P.O. BOX 9996
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 S MIDLAND BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-461-5057
Practice Address - Fax:208-461-5210
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27080225100000X
IDPT-5826225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist