Provider Demographics
NPI:1013317841
Name:BRYSON, TIM
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:BRYSON
Suffix:
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 1:21 NATIONAL GUARD RD
Mailing Address - Street 2:APT 813B
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-4765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 NATIONAL GUARD RD
Practice Address - Street 2:APT 813B
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-4765
Practice Address - Country:US
Practice Address - Phone:513-368-9144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC103069772390200000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer