Provider Demographics
NPI:1003230103
Name:OSWALT, BRYANNA
Entity Type:Individual
Prefix:
First Name:BRYANNA
Middle Name:
Last Name:OSWALT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4450 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7213
Practice Address - Country:US
Practice Address - Phone:321-726-2860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT1742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health