Provider Demographics
NPI:1538489588
Name:BRYANT, VIRLETTA C (PHD, LICSW)
Entity Type:Individual
Prefix:DR
First Name:VIRLETTA
Middle Name:C
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PHD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 WOODELVES WAY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2451
Mailing Address - Country:US
Mailing Address - Phone:301-868-4640
Mailing Address - Fax:
Practice Address - Street 1:2500 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-3633
Practice Address - Country:US
Practice Address - Phone:301-404-2127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15447104100000X
DCLC500782971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker