Provider Demographics
NPI:1033745138
Name:BRYAN, LEROY
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:BRYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 ROSEBUD RD APT 521
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8961
Mailing Address - Country:US
Mailing Address - Phone:706-528-8053
Mailing Address - Fax:
Practice Address - Street 1:1175 GREEN ST SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-5407
Practice Address - Country:US
Practice Address - Phone:770-929-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional