Provider Demographics
NPI:1811183445
Name:GRAHAM, BRYAN LESLIE (MPT)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:LESLIE
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 SE OCEAN BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2425
Mailing Address - Country:US
Mailing Address - Phone:772-283-3820
Mailing Address - Fax:772-283-3825
Practice Address - Street 1:931 SE OCEAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2425
Practice Address - Country:US
Practice Address - Phone:772-283-3820
Practice Address - Fax:772-283-3825
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT17379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY9760YMedicare PIN