1356445902 NPI number — MRS. BRENDA KAY BRYANT LMSW

Table of content: MRS. BRENDA KAY BRYANT LMSW (NPI 1356445902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356445902 NPI number — MRS. BRENDA KAY BRYANT LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYANT
Provider First Name:
BRENDA
Provider Middle Name:
KAY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MITCHELL
Provider Other First Name:
BRENDA
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356445902
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 N SAGINAW ST
Provider Second Line Business Mailing Address:
SUITE 813
Provider Business Mailing Address City Name:
PONTIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48342-2134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-451-0540
Provider Business Mailing Address Fax Number:
248-451-0544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 N SAGINAW ST
Provider Second Line Business Practice Location Address:
SUITE 813
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48342-2134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-451-0540
Provider Business Practice Location Address Fax Number:
248-451-0544
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801058936 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8008970060 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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