Provider Demographics
NPI:1437622255
Name:BRYAN, MARY ELIZABETH (LMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:BRYAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 6TH AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-1226
Mailing Address - Country:US
Mailing Address - Phone:917-671-8768
Mailing Address - Fax:
Practice Address - Street 1:218 6TH AVE APT 2D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-1226
Practice Address - Country:US
Practice Address - Phone:917-671-8768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
072316-1104100000X
NY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker