Provider Demographics
NPI:1104328657
Name:KIDD, BRYAN KEITH (PT)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEITH
Last Name:KIDD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 PARKDALE AVENUE
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660
Mailing Address - Country:US
Mailing Address - Phone:231-398-1166
Mailing Address - Fax:
Practice Address - Street 1:1465 PARKDALE AVENUE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660
Practice Address - Country:US
Practice Address - Phone:231-398-1166
Practice Address - Fax:231-398-1499
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist