Provider Demographics
NPI:1881456515
Name:QUEVEDO, BRYANT (OTR/L)
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:QUEVEDO
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 JACOBIN ST NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-9423
Mailing Address - Country:US
Mailing Address - Phone:321-848-8390
Mailing Address - Fax:
Practice Address - Street 1:5405 BABCOCK ST NE BAY FL32905
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5020
Practice Address - Country:US
Practice Address - Phone:321-722-0660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24295225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist