Provider Demographics
NPI:1831685338
Name:BRYANT, KRISTA DENDOR
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:DENDOR
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 1:35 PERRY AVE
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2433
Mailing Address - Country:US
Mailing Address - Phone:518-867-9731
Mailing Address - Fax:
Practice Address - Street 1:673 COLUMBIA TPKE
Practice Address - Street 2:
Practice Address - City:EAST GREENBUSH
Practice Address - State:NY
Practice Address - Zip Code:12061-2130
Practice Address - Country:US
Practice Address - Phone:518-233-0544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-08
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022658225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty