Provider Demographics
NPI:1679940589
Name:BRIESE, KEYLA MACHELL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KEYLA
Middle Name:MACHELL
Last Name:BRIESE
Suffix:
Gender:F
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 1:34409 N LEVI CT
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-4474
Mailing Address - Country:US
Mailing Address - Phone:406-390-2543
Mailing Address - Fax:
Practice Address - Street 1:34409 N LEVI CT
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85142-4474
Practice Address - Country:US
Practice Address - Phone:406-390-2543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11808PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist