Provider Demographics
NPI:1699183319
Name:EDDY, BRIAN (OTR)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:EDDY
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4672 ARDENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-4054
Mailing Address - Country:US
Mailing Address - Phone:317-985-4827
Mailing Address - Fax:
Practice Address - Street 1:267 N STATE HIGHWAY 360
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9073
Practice Address - Country:US
Practice Address - Phone:817-778-9361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99062900A225X00000X
TX121211225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist