Provider Demographics
NPI:1477030682
Name:BRYAN, KALI (PTA)
Entity Type:Individual
Prefix:
First Name:KALI
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 TEAK LN
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-6621
Mailing Address - Country:US
Mailing Address - Phone:303-521-2396
Mailing Address - Fax:
Practice Address - Street 1:2218 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-1624
Practice Address - Country:US
Practice Address - Phone:575-748-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPTA1524225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant