Provider Demographics
NPI:1598500878
Name:CELIS, BRYAN DANIEL
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:DANIEL
Last Name:CELIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 PIONEER RD APT 156
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-4987
Mailing Address - Country:US
Mailing Address - Phone:208-410-5659
Mailing Address - Fax:
Practice Address - Street 1:36 PROFESSIONAL PLZ STE 110
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2049
Practice Address - Country:US
Practice Address - Phone:208-359-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics