Provider Demographics
NPI:1891454450
Name:BRYANT, CARLA RENEE
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:RENEE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:RENEE
Other - Last Name:PENNINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:925 N 1464 RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-9184
Mailing Address - Country:US
Mailing Address - Phone:785-766-9958
Mailing Address - Fax:
Practice Address - Street 1:925 N 1464 RD
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-9184
Practice Address - Country:US
Practice Address - Phone:785-766-9958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01153224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant