Provider Demographics
NPI:1033582309
Name:BRYAN, CYNTHIA (BSW, RSW, LAC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:BSW, RSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 FELICIA AVE
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282-8203
Mailing Address - Country:US
Mailing Address - Phone:318-574-1232
Mailing Address - Fax:318-574-8646
Practice Address - Street 1:1705 FELICIA AVE
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-8203
Practice Address - Country:US
Practice Address - Phone:318-574-1232
Practice Address - Fax:318-574-8646
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA710101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1033582309Medicaid