Provider Demographics
NPI:1417238767
Name:BRYAN, KEISHA S (MSW, LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:S
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7827 TUCKAHOE CT
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2599
Mailing Address - Country:US
Mailing Address - Phone:301-526-2396
Mailing Address - Fax:301-604-1310
Practice Address - Street 1:3711 INA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-2322
Practice Address - Country:US
Practice Address - Phone:301-526-2396
Practice Address - Fax:301-604-1310
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD143941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical