Provider Demographics
NPI:1164772802
Name:BRYANT, ELLANISHA LATASHA
Entity Type:Individual
Prefix:
First Name:ELLANISHA
Middle Name:LATASHA
Last Name:BRYANT
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 1:3145 E FLAMINGO RD
Mailing Address - Street 2:2008
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-4352
Mailing Address - Country:US
Mailing Address - Phone:702-782-4122
Mailing Address - Fax:
Practice Address - Street 1:3145 E FLAMINGO RD
Practice Address - Street 2:APT 2008
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-4352
Practice Address - Country:US
Practice Address - Phone:702-782-4122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1649576471Medicaid