Provider Demographics
NPI:1073593968
Name:BRYANT, TINA YVETTE (LMSW)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:YVETTE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 A SECOND ST, SE
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND AFB
Mailing Address - State:NM
Mailing Address - Zip Code:87117-0001
Mailing Address - Country:US
Mailing Address - Phone:505-846-3305
Mailing Address - Fax:505-846-3295
Practice Address - Street 1:2050 A SECOND ST, SE
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-0001
Practice Address - Country:US
Practice Address - Phone:505-846-3305
Practice Address - Fax:505-846-3295
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX324201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical