Basic Information
| Provider Information | |||||||||
| NPI: | 1679020200 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BRYSON | ||||||||
| FirstName: | RAVEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3041 SHENANDOAH DR | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760213236 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 CHARLEVOIX DRIVE SOUTHEAST SUITE 200 | ||||||||
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| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169755000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2016 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT291271 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1216883 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT 25615 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PTL.0013458 | CO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.