Healthcare Provider Details

I. General information

NPI: 1609716877
Provider Name (Legal Business Name): BRYLEE RUSSELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W MAIN ST. SERENE PELVIC PHYSICAL THERAPY SUITE 4
TUTTLE OK
73089
US

IV. Provider business mailing address

460 N PEBBLE CREEK TERRANCE APT 302
MUSTANG OK
73064
US

V. Phone/Fax

Practice location:
  • Phone: 405-463-4634
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4022
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: