Provider Demographics
NPI:1780648147
Name:COLEY, BRIAN LEE (ATC/LAT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
Last Name:COLEY
Suffix:
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 S HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5607
Mailing Address - Country:US
Mailing Address - Phone:918-627-3390
Mailing Address - Fax:918-664-2134
Practice Address - Street 1:3905 S HUDSON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5607
Practice Address - Country:US
Practice Address - Phone:918-627-3390
Practice Address - Fax:918-664-2134
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAT94390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program