Provider Demographics
NPI:1891154746
Name:KELLEY, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:KELLEY
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 1:760 SAN RAMON VALLEY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4057
Mailing Address - Country:US
Mailing Address - Phone:925-743-8905
Mailing Address - Fax:
Practice Address - Street 1:760 SAN RAMON VALLEY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4057
Practice Address - Country:US
Practice Address - Phone:925-743-8905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-21
Last Update Date:2016-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16012225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist