Provider Demographics
NPI:1326629817
Name:HAVERLY, BRYAN (RMP)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:HAVERLY
Suffix:
Gender:M
Credentials:RMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6207 S OSBORNE RD
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3915
Mailing Address - Country:US
Mailing Address - Phone:301-814-1986
Mailing Address - Fax:
Practice Address - Street 1:6207 S OSBORNE RD
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3915
Practice Address - Country:US
Practice Address - Phone:301-814-1986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR03343225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist