Provider Demographics
NPI:1346027265
Name:BARRY, COLM TYLER (PTA)
Entity Type:Individual
Prefix:MR
First Name:COLM
Middle Name:TYLER
Last Name:BARRY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-1324
Mailing Address - Country:US
Mailing Address - Phone:443-949-5509
Mailing Address - Fax:
Practice Address - Street 1:5930 ADOBE RD
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-2356
Practice Address - Country:US
Practice Address - Phone:760-367-1743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3958225200000X
CA49845225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant