Provider Demographics
NPI:1912952649
Name:BRYANT, KELLI A (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:A
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 S KOKE MILL RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-9252
Mailing Address - Country:US
Mailing Address - Phone:217-547-9100
Mailing Address - Fax:217-547-9245
Practice Address - Street 1:1301 S KOKE MILL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-9252
Practice Address - Country:US
Practice Address - Phone:217-547-9108
Practice Address - Fax:217-547-9245
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700013533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist