Healthcare Provider Details

I. General information

NPI: 1114271913
Provider Name (Legal Business Name): REBEKAH KAYE BRYANT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 S LAKE PARK AVE UNIT A
HOBART IN
46342-6635
US

IV. Provider business mailing address

1611 BEECH ST
VALPARAISO IN
46383-5109
US

V. Phone/Fax

Practice location:
  • Phone: 219-947-3637
  • Fax:
Mailing address:
  • Phone: 919-946-1670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06004480A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: