Provider Demographics
NPI:1760953848
Name:O'BRYANT, THERESA CLARK (BCTMB, LMT)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:CLARK
Last Name:O'BRYANT
Suffix:
Gender:F
Credentials:BCTMB, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 WALKER ST STE 746
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4258
Mailing Address - Country:US
Mailing Address - Phone:313-757-3610
Mailing Address - Fax:
Practice Address - Street 1:4801 CHRYSLER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1463
Practice Address - Country:US
Practice Address - Phone:313-757-3610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000926225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist