Provider Demographics
NPI:1417253246
Name:BRYANT, TERI A (LMP)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:A
Last Name:BRYANT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3103
Mailing Address - Country:US
Mailing Address - Phone:360-423-2037
Mailing Address - Fax:360-423-9320
Practice Address - Street 1:1060 HUDSON ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3103
Practice Address - Country:US
Practice Address - Phone:360-423-2037
Practice Address - Fax:360-423-9320
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60126532174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist