Provider Demographics
NPI:1134511124
Name:BRYANT, EDNY JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDNY
Middle Name:JOSEPH
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 MARIPOSA DR
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-2325
Mailing Address - Country:US
Mailing Address - Phone:706-284-3682
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP, BLDG 4554
Practice Address - Street 2:ATTN: 59 MDW/SGHC
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-7631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-27
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005607103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical