Healthcare Provider Details

I. General information

NPI: 1720351489
Provider Name (Legal Business Name): BRYANNA LYNN DYKES COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N HURSTBOURNE PKWY STE 200
LOUISVILLE KY
40222-5158
US

IV. Provider business mailing address

3150 KERRY DR
BEAVERCREEK OH
45434-6363
US

V. Phone/Fax

Practice location:
  • Phone: 502-412-5847
  • Fax:
Mailing address:
  • Phone: 937-522-5302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number04516
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: