Provider Demographics
NPI:1821540618
Name:KOUDIM, BRYAN (PTA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:KOUDIM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S78W18465 LIONS PARK DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-8704
Mailing Address - Country:US
Mailing Address - Phone:262-309-1253
Mailing Address - Fax:
Practice Address - Street 1:9047 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-2808
Practice Address - Country:US
Practice Address - Phone:414-453-9290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI254819246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other