Provider Demographics
NPI:1942717962
Name:TRYON, BRENDA (MOTR/L)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:TRYON
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:GRANADOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10604 MIERA DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114
Mailing Address - Country:US
Mailing Address - Phone:505-730-7058
Mailing Address - Fax:
Practice Address - Street 1:2410 19TH ST SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4857
Practice Address - Country:US
Practice Address - Phone:505-730-7058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3706225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3706OtherNM STATE