Provider Demographics
NPI:1235647678
Name:KEISTER, BRIANNA MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:MARIE
Last Name:KEISTER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 BRYANT IRVIN RD N STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7673
Mailing Address - Country:US
Mailing Address - Phone:817-738-9866
Mailing Address - Fax:
Practice Address - Street 1:201 W. LANCASTER AVE
Practice Address - Street 2:417
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102
Practice Address - Country:US
Practice Address - Phone:817-738-9866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113731225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist