Provider Demographics
NPI:1407179252
Name:WHALEN, BRYANT
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:WHALEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-5818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 W PARK AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3929
Practice Address - Country:US
Practice Address - Phone:217-373-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health