Provider Demographics
NPI:1053100040
Name:BRAY, BRYANNA R (LMT)
Entity type:Individual
Prefix:
First Name:BRYANNA
Middle Name:R
Last Name:BRAY
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:SPRING BAY
Mailing Address - State:IL
Mailing Address - Zip Code:61611-9035
Mailing Address - Country:US
Mailing Address - Phone:309-214-8449
Mailing Address - Fax:
Practice Address - Street 1:1409 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-2371
Practice Address - Country:US
Practice Address - Phone:309-415-0275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.023467225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist