Provider Demographics
NPI:1457846594
Name:WILMA L. BRYANT PSYCHOTHERAPY LTD
Entity Type:Organization
Organization Name:WILMA L. BRYANT PSYCHOTHERAPY LTD
Other - Org Name:WILMA L BRYANT LCSW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOTHERAPY
Authorized Official - Prefix:
Authorized Official - First Name:WILMA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:217-637-7815
Mailing Address - Street 1:2807 WOODHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7573
Mailing Address - Country:US
Mailing Address - Phone:217-637-7715
Mailing Address - Fax:
Practice Address - Street 1:100 N CHESTNUT ST STE 229
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4856
Practice Address - Country:US
Practice Address - Phone:217-637-7815
Practice Address - Fax:844-693-1411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149005877261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health