Provider Demographics
NPI:1023408143
Name:BRYANT, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 FLETCHER PKWY
Mailing Address - Street 2:APT 23
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-2178
Mailing Address - Country:US
Mailing Address - Phone:513-546-0492
Mailing Address - Fax:
Practice Address - Street 1:2675 FLETCHER PKWY
Practice Address - Street 2:APT 23
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2178
Practice Address - Country:US
Practice Address - Phone:513-546-0492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1750224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant