Provider Demographics
NPI:1225134430
Name:BRYAN, JEFFREY IRA (MSW)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:IRA
Last Name:BRYAN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 BRIARWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-6329
Mailing Address - Country:US
Mailing Address - Phone:516-939-0117
Mailing Address - Fax:516-939-0384
Practice Address - Street 1:73 BRIARWOOD LANE
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-6329
Practice Address - Country:US
Practice Address - Phone:516-939-0117
Practice Address - Fax:516-939-0384
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR020536-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR47488Medicare UPIN
NYN28501JBMedicare ID - Type Unspecified