Provider Demographics
NPI:1497941470
Name:BRYAN, VICKI S (MT,MTI)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:S
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MT,MTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64549
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79464-4549
Mailing Address - Country:US
Mailing Address - Phone:806-438-2125
Mailing Address - Fax:806-794-9283
Practice Address - Street 1:1717 NORFOLK AVE BLDG B
Practice Address - Street 2:#1371
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-6035
Practice Address - Country:US
Practice Address - Phone:806-792-2085
Practice Address - Fax:806-794-9283
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMIO1968225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist