Provider Demographics
NPI:1720802200
Name:BRYANT, MIKAYLA ALEXIS (COTA)
Entity type:Individual
Prefix:MISS
First Name:MIKAYLA
Middle Name:ALEXIS
Last Name:BRYANT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6319 FAULKNER DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-6154
Mailing Address - Country:US
Mailing Address - Phone:804-980-6541
Mailing Address - Fax:
Practice Address - Street 1:906 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-1128
Practice Address - Country:US
Practice Address - Phone:804-798-3291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA522634224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant