Provider Demographics
NPI:1154572279
Name:LAIRD, BRIANNA BETHANY (DPT)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:BETHANY
Last Name:LAIRD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:BETHANY
Other - Last Name:DITTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 636002
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80163-6002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2490 S 11TH ST
Practice Address - Street 2:SUITE 8
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2175
Practice Address - Country:US
Practice Address - Phone:269-372-0436
Practice Address - Fax:269-372-0483
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014066225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist