=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568937977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYRA L O'BRYANT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2018
-----------------------------------------------------
Last Update Date | 10/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6200 OREGON AVE NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20015-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-541-0403
-----------------------------------------------------
Fax | 202-244-1329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6200 OREGON AVE NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20015-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-541-0403
-----------------------------------------------------
Fax | 202-244-1329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------