Provider Demographics
NPI:1104171156
Name:BRYANT, STACIA T (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:T
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 ORLA CT
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-4402
Mailing Address - Country:US
Mailing Address - Phone:908-309-8241
Mailing Address - Fax:
Practice Address - Street 1:14 BRIDGEWATERS DR STE A
Practice Address - Street 2:
Practice Address - City:OCEANPORT
Practice Address - State:NJ
Practice Address - Zip Code:07757-1184
Practice Address - Country:US
Practice Address - Phone:732-542-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA002110002251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics