=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972138097
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WYNETTE ANN BRYANT LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2020
-----------------------------------------------------
Last Update Date | 03/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2876 LUDLOW RD # 1E
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44120-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-791-3131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2876 LUDLOW RD # 1E
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44120-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-791-3131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 33-020993
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------