Provider Demographics
NPI:1558806299
Name:DECLERK, BRYAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:DECLERK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 CHOCTAW CENTER
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:72529-2702
Mailing Address - Country:US
Mailing Address - Phone:870-856-4325
Mailing Address - Fax:870-856-4327
Practice Address - Street 1:31 CHOCTAW CENTER
Practice Address - Street 2:
Practice Address - City:CHEROKEE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:72529-2702
Practice Address - Country:US
Practice Address - Phone:870-856-4325
Practice Address - Fax:870-856-4327
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3540225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist