Provider Demographics
NPI:1225684921
Name:BRYAN, KIMBERLY (LCSWA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 AVENT HL APT A3
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-3491
Mailing Address - Country:US
Mailing Address - Phone:303-898-3904
Mailing Address - Fax:
Practice Address - Street 1:136 US 70 HWY E STE 201
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3982
Practice Address - Country:US
Practice Address - Phone:919-791-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-18
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0177371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical