Healthcare Provider Details

I. General information

NPI: 1265950687
Provider Name (Legal Business Name): CALICIA BRYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 BRIDGE ST BLDG 5B-132
PHILADELPHIA PA
19137-1300
US

IV. Provider business mailing address

151 E KINGS HWY UNIT 162
MAPLE SHADE NJ
08052-3428
US

V. Phone/Fax

Practice location:
  • Phone: 215-772-0101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: