Provider Demographics
NPI:1952534240
Name:WIDDISON, BRYAN LORENZO (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:LORENZO
Last Name:WIDDISON
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 1:22480 PEBBLE BROOK LN
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-8390
Mailing Address - Country:US
Mailing Address - Phone:303-550-3268
Mailing Address - Fax:
Practice Address - Street 1:22480 PEBBLE BROOK LN
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-8390
Practice Address - Country:US
Practice Address - Phone:303-550-3268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2024-02-01
Deactivation Date:2019-10-23
Deactivation Code:
Reactivation Date:2024-02-01
Provider Licenses
StateLicense IDTaxonomies
COOT.0003001225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist