Provider Demographics
NPI:1437174042
Name:BRYAN, TAMARA S (PHD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:S
Last Name:BRYAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 AVENUE OF THE AMERICAS
Mailing Address - Street 2:SUITE 1705
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-3507
Mailing Address - Country:US
Mailing Address - Phone:212-523-2965
Mailing Address - Fax:212-643-0861
Practice Address - Street 1:875 AVENUE OF THE AMERICAS
Practice Address - Street 2:SUITE 1705
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3507
Practice Address - Country:US
Practice Address - Phone:212-523-2965
Practice Address - Fax:212-643-0861
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00015230103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02472053Medicaid
NYV781S1Medicare ID - Type Unspecified