Provider Demographics
NPI:1114305562
Name:BRYAN, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BRYAN
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 1:1412 CRAIN HWY N
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-9306
Mailing Address - Country:US
Mailing Address - Phone:410-766-6624
Mailing Address - Fax:410-766-0240
Practice Address - Street 1:1412 CRAIN HWY N
Practice Address - Street 2:SUITE 1B
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-9306
Practice Address - Country:US
Practice Address - Phone:410-766-6624
Practice Address - Fax:410-766-0240
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD135711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical