Provider Demographics
NPI:1639917586
Name:BRYAN, KELLY (DT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2807 STARLING LN
Mailing Address - Street 2:
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-2638
Mailing Address - Country:US
Mailing Address - Phone:847-915-9850
Mailing Address - Fax:618-503-0263
Practice Address - Street 1:4501 HILL RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-3519
Practice Address - Country:US
Practice Address - Phone:618-830-6562
Practice Address - Fax:618-503-0263
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist