Provider Demographics
NPI:1073119764
Name:KEITH, BRYANT MITCHELL (LMFT; SB-LMFT)
Entity Type:Individual
Prefix:MR
First Name:BRYANT
Middle Name:MITCHELL
Last Name:KEITH
Suffix:
Gender:M
Credentials:LMFT; SB-LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 MCKEE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4800
Mailing Address - Country:US
Mailing Address - Phone:203-980-6089
Mailing Address - Fax:
Practice Address - Street 1:222 MCKEE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4800
Practice Address - Country:US
Practice Address - Phone:203-980-6089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CT2425106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist