Provider Demographics
NPI:1306018049
Name:BRYANT, AUDRA JEAN (MS,LPC, LSW)
Entity Type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:JEAN
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MS,LPC, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 E PLAZA ST STE B
Mailing Address - Street 2:PMB#137
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5982
Mailing Address - Country:US
Mailing Address - Phone:208-371-5433
Mailing Address - Fax:
Practice Address - Street 1:228 E PLAZA ST STE B
Practice Address - Street 2:PMB#137
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5982
Practice Address - Country:US
Practice Address - Phone:208-371-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3473101YP2500X
IDLSW-2046104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker