Provider Demographics
NPI:1497895452
Name:BRYANT, GERALD J (PHD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:J
Last Name:BRYANT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 39TH AVE
Mailing Address - Street 2:R15
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-1172
Mailing Address - Country:US
Mailing Address - Phone:212-644-5889
Mailing Address - Fax:
Practice Address - Street 1:141 E 55TH ST
Practice Address - Street 2:9B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-4030
Practice Address - Country:US
Practice Address - Phone:212-644-5889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009841-1103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01758869Medicaid
NYVOB361Medicare ID - Type Unspecified
NY01758869Medicaid