Provider Demographics
NPI:1174837959
Name:BRYANT, EDWIN LEON II (BA,BS)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:LEON
Last Name:BRYANT
Suffix:II
Gender:M
Credentials:BA,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 343
Mailing Address - Street 2:
Mailing Address - City:LANGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73050-0343
Mailing Address - Country:US
Mailing Address - Phone:281-777-8897
Mailing Address - Fax:
Practice Address - Street 1:4030 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5207
Practice Address - Country:US
Practice Address - Phone:405-528-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health