Provider Demographics
NPI:1548587694
Name:BEASLEY, BRYAN DAVIS (ATC/L)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:DAVIS
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 GOVERNORS CT
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-4272
Mailing Address - Country:US
Mailing Address - Phone:615-604-3399
Mailing Address - Fax:
Practice Address - Street 1:2659 ABUTMENT RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-4887
Practice Address - Country:US
Practice Address - Phone:706-532-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT002017225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner