Healthcare Provider Details

I. General information

NPI: 1255004289
Provider Name (Legal Business Name): BRIELLE HOLLY BRIGHT PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12380 DEPAUL DR
BRIDGETON MO
63044
US

IV. Provider business mailing address

4217 BLAINE AVE APT C
SAINT LOUIS MO
63110-2484
US

V. Phone/Fax

Practice location:
  • Phone: 314-447-9710
  • Fax:
Mailing address:
  • Phone: 317-413-4583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2021024429
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: