Provider Demographics
NPI:1376877738
Name:BRYANT, ANN LAKE (MA)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:LAKE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 N HUMPHREY AVE
Mailing Address - Street 2:APT C1
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2540
Mailing Address - Country:US
Mailing Address - Phone:708-948-7193
Mailing Address - Fax:
Practice Address - Street 1:6918 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3334
Practice Address - Country:US
Practice Address - Phone:708-745-5277
Practice Address - Fax:708-795-4834
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health