Healthcare Provider Details

I. General information

NPI: 1679020200
Provider Name (Legal Business Name): RAVEN BRYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 CHARLEVOIX DRIVE SOUTHEAST SUITE 200
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

3041 SHENANDOAH DR
BEDFORD TX
76021-3236
US

V. Phone/Fax

Practice location:
  • Phone: 616-975-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT291271
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1216883
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 25615
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0013458
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: