Provider Demographics
NPI:1346369949
Name:BRYAN, AMY JOLENE (COTAL)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JOLENE
Last Name:BRYAN
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 FREEDOM ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-3629
Mailing Address - Country:US
Mailing Address - Phone:570-326-4083
Mailing Address - Fax:
Practice Address - Street 1:245 E 8TH ST
Practice Address - Street 2:
Practice Address - City:WATSONTOWN
Practice Address - State:PA
Practice Address - Zip Code:17777-1033
Practice Address - Country:US
Practice Address - Phone:570-538-2561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP003328L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant