Provider Demographics
NPI:1649387895
Name:BRYAN, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:ROCHEPORT
Mailing Address - State:MO
Mailing Address - Zip Code:65279-9812
Mailing Address - Country:US
Mailing Address - Phone:573-698-2002
Mailing Address - Fax:
Practice Address - Street 1:402 N KEENE ST STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6986
Practice Address - Country:US
Practice Address - Phone:573-874-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO114829OtherLICENSE #