Provider Demographics
NPI:1154814754
Name:LUONG, BRYANT (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:LUONG
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1528
Mailing Address - Country:US
Mailing Address - Phone:949-232-5834
Mailing Address - Fax:
Practice Address - Street 1:500 TAMAL PLZ STE 527
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1187
Practice Address - Country:US
Practice Address - Phone:949-232-5834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18396225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2597222OtherMERCER/PROLIABILITY