Provider Demographics
NPI:1790904704
Name:COLEY, BRIAN D (OT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:D
Last Name:COLEY
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 SUNNYPARK
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-5575
Mailing Address - Country:US
Mailing Address - Phone:909-894-8283
Mailing Address - Fax:
Practice Address - Street 1:1710 SUNNYPARK
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-5575
Practice Address - Country:US
Practice Address - Phone:909-894-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT3621225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ23500ZMedicare ID - Type UnspecifiedPPIN