Provider Demographics
NPI:1457629008
Name:BRYAN, ANDRE
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:BRYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 N ORANGE BLOSSOM TRL
Mailing Address - Street 2:SUITE 222
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-1042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5104 N ORANGE BLOSSOM TRL
Practice Address - Street 2:SUITE 222
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-1042
Practice Address - Country:US
Practice Address - Phone:321-426-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-11
Last Update Date:2013-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 8235101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health