Healthcare Provider Details

I. General information

NPI: 1841853033
Provider Name (Legal Business Name): BRELON T BRYANT LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 HIGHWAY 98 W
SUMMIT MS
39666-9132
US

IV. Provider business mailing address

826 PRIMOS AVE
JACKSON MS
39209-6137
US

V. Phone/Fax

Practice location:
  • Phone: 601-276-3900
  • Fax:
Mailing address:
  • Phone: 228-627-1604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6512
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: