Provider Demographics
NPI:1497168603
Name:BRYANT, JOHN (MS LMFT LCAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:MS LMFT LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10347 OREILLY DR
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-9565
Mailing Address - Country:US
Mailing Address - Phone:219-866-2478
Mailing Address - Fax:
Practice Address - Street 1:10347 OREILLY DR
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-9565
Practice Address - Country:US
Practice Address - Phone:219-866-2478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8700965A101YA0400X
IN35001686A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)