Provider Demographics
NPI:1871042721
Name:O'BRYAN, RICHARD III
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:O'BRYAN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18738 NORTHROP ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32833-4114
Mailing Address - Country:US
Mailing Address - Phone:407-925-0952
Mailing Address - Fax:
Practice Address - Street 1:155 CRANES ROOST BLVD
Practice Address - Street 2:SUITE #2090
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-3468
Practice Address - Country:US
Practice Address - Phone:407-494-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 15024224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant