Provider Demographics
NPI:1578880928
Name:BRYANT, MAVIS (OTR/LMT)
Entity Type:Individual
Prefix:
First Name:MAVIS
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:OTR/LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 TANSBORO DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-1748
Mailing Address - Country:US
Mailing Address - Phone:386-810-2218
Mailing Address - Fax:
Practice Address - Street 1:2716 TANSBORO DR
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-1748
Practice Address - Country:US
Practice Address - Phone:386-810-2218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 11500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist