Provider Demographics
NPI:1275548604
Name:BRYANT, IVY
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
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 1:204 N KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5TH AVE & ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IN
Practice Address - Zip Code:60141
Practice Address - Country:US
Practice Address - Phone:708-202-8387
Practice Address - Fax:708-202-2087
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker