Provider Demographics
NPI:1417315946
Name:O'BRYANT, JOHNNY LEE II (CIT 3419 3/19/16)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:LEE
Last Name:O'BRYANT
Suffix:II
Gender:M
Credentials:CIT 3419 3/19/16
Other - Prefix:MR
Other - First Name:JOHNNY
Other - Middle Name:LEE
Other - Last Name:O'BRYANT
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:CIT 3419 03/31/2016
Mailing Address - Street 1:4255 E BROOKSTOWN DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70805-4603
Mailing Address - Country:US
Mailing Address - Phone:225-927-0770
Mailing Address - Fax:225-927-0771
Practice Address - Street 1:4255 E BROOKSTOWN DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-4603
Practice Address - Country:US
Practice Address - Phone:225-927-0770
Practice Address - Fax:225-927-0771
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACIT 3419101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)