Provider Demographics
NPI:1932333580
Name:PICKENS, BRYAN B (PT, DSC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:B
Last Name:PICKENS
Suffix:
Gender:M
Credentials:PT, DSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SCHOFIELD RD, BLDG 1179
Mailing Address - Street 2:ATTN: PHYSICAL THERAPY
Mailing Address - City:FT. SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7577
Mailing Address - Country:US
Mailing Address - Phone:210-854-7762
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-808-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
COPT00011207225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171000000XOther Service ProvidersMilitary Health Care Provider