Provider Demographics
NPI:1003128174
Name:ROBERTS, BRYAN JAMES (COTA)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JAMES
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 ROCKWELL DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-9316
Mailing Address - Country:US
Mailing Address - Phone:989-633-5372
Mailing Address - Fax:
Practice Address - Street 1:2121 ROCKWELL DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-9316
Practice Address - Country:US
Practice Address - Phone:989-633-5372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202006620224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant