Provider Demographics
NPI:1891343398
Name:RAYBON, BRYCEN NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:BRYCEN
Middle Name:NICOLE
Last Name:RAYBON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 2ND AVE APT 3F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-3520
Mailing Address - Country:US
Mailing Address - Phone:972-249-7503
Mailing Address - Fax:
Practice Address - Street 1:164 W 79TH ST APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6440
Practice Address - Country:US
Practice Address - Phone:212-712-2014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120093225X00000X
NY023718225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty