Provider Demographics
NPI:1457305831
Name:BRYANT, THERESA ELLEN (MED LMFT)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ELLEN
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MED LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 SOMERVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3244
Mailing Address - Country:US
Mailing Address - Phone:857-998-2168
Mailing Address - Fax:
Practice Address - Street 1:131 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5752
Practice Address - Country:US
Practice Address - Phone:857-998-2168
Practice Address - Fax:617-491-2020
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1265106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist