Provider Demographics
NPI:1255952578
Name:CROWDER, BRYAN RUSSELL JR
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:RUSSELL
Last Name:CROWDER
Suffix:JR
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 1:202 LOST RIVER LNDG
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-2161
Mailing Address - Country:US
Mailing Address - Phone:318-355-0583
Mailing Address - Fax:
Practice Address - Street 1:442 E FRENCHMANS BEND RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8852
Practice Address - Country:US
Practice Address - Phone:318-503-9789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08304225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist