Healthcare Provider Details

I. General information

NPI: 1700553138
Provider Name (Legal Business Name): BRYAN HARTSFIELD COOLEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 JOE KNOX AVE
MOORESVILLE NC
28117-9169
US

IV. Provider business mailing address

8918 BLAKENEY PROFESSIONAL DR STE 120
CHARLOTTE NC
28277-6692
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-2779
  • Fax:
Mailing address:
  • Phone: 704-900-8960
  • Fax: 704-817-9523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberP20752
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP20752
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberP20752
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: