Provider Demographics
NPI:1851052518
Name:HENNINGTON, BRYSON T
Entity type:Individual
Prefix:
First Name:BRYSON
Middle Name:T
Last Name:HENNINGTON
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 1:1717 N VERDUGO RD APT 251
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2968
Mailing Address - Country:US
Mailing Address - Phone:512-917-4913
Mailing Address - Fax:
Practice Address - Street 1:1717 N VERDUGO RD APT 251
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-2968
Practice Address - Country:US
Practice Address - Phone:512-917-4913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88924225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist