Provider Demographics
NPI:1558014886
Name:BRYAN, KIMBERLY SUE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:BRYAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:SUE
Other - Last Name:CAVANAUGH-SCARCELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:104 CATHY LN
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32112-4122
Mailing Address - Country:US
Mailing Address - Phone:315-897-6597
Mailing Address - Fax:
Practice Address - Street 1:101 EUCALYPTUS AVE
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-2407
Practice Address - Country:US
Practice Address - Phone:386-698-0841
Practice Address - Fax:386-698-0845
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012557-01225X00000X
FL20540225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist