Provider Demographics
NPI:1639316201
Name:BRYSON, DIANE S (LAC, PTA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:S
Last Name:BRYSON
Suffix:
Gender:F
Credentials:LAC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 36TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712-1913
Mailing Address - Country:US
Mailing Address - Phone:240-687-6006
Mailing Address - Fax:
Practice Address - Street 1:3202 TOWER OAKS BLVD
Practice Address - Street 2:SUITE 280
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4219
Practice Address - Country:US
Practice Address - Phone:301-231-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01084171100000X
MDA1766225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No171100000XOther Service ProvidersAcupuncturist