Healthcare Provider Details

I. General information

NPI: 1558705335
Provider Name (Legal Business Name): BRYANT EDWARDS OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 N HOOVER ST
LOS ANGELES CA
90027-6008
US

IV. Provider business mailing address

1320 N HOOVER ST
LOS ANGELES CA
90027-6008
US

V. Phone/Fax

Practice location:
  • Phone: 310-382-0076
  • Fax:
Mailing address:
  • Phone: 310-382-0076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number8359
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: