Provider Demographics
NPI:1376908517
Name:BRABHAM, RYAN MARSHALL (PTA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:MARSHALL
Last Name:BRABHAM
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 1:1705 MIDDLE FRK
Mailing Address - Street 2:
Mailing Address - City:REEDY
Mailing Address - State:WV
Mailing Address - Zip Code:25270-9781
Mailing Address - Country:US
Mailing Address - Phone:304-989-0099
Mailing Address - Fax:
Practice Address - Street 1:825 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1035
Practice Address - Country:US
Practice Address - Phone:304-927-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001519225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant