1457846594 NPI number — WILMA L. BRYANT PSYCHOTHERAPY LTD

Table of content: (NPI 1457846594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457846594 NPI number — WILMA L. BRYANT PSYCHOTHERAPY LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILMA L. BRYANT PSYCHOTHERAPY LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457846594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2807 WOODHAVEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61822-7573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-637-7715
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N CHESTNUT ST STE 229
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820-4856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-637-7815
Provider Business Practice Location Address Fax Number:
844-693-1411
Provider Enumeration Date:
06/29/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BRYANT
Authorized Official First Name:
WILMA
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PSYCHOTHERAPY
Authorized Official Telephone Number:
217-637-7815

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  149005877 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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