Provider Demographics
NPI:1366635625
Name:BRYAN-OLIVER, TRACY ANNE (PT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANNE
Last Name:BRYAN-OLIVER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 GREENSTABLE GATE LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-9413
Mailing Address - Country:US
Mailing Address - Phone:301-328-1456
Mailing Address - Fax:
Practice Address - Street 1:4409 E WEST HWY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1058
Practice Address - Country:US
Practice Address - Phone:301-985-3221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist