Provider Demographics
NPI:1558140921
Name:BRYANT, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 S BELLEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:FREEBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62243-1501
Mailing Address - Country:US
Mailing Address - Phone:314-534-8689
Mailing Address - Fax:
Practice Address - Street 1:4414 N FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63107-1812
Practice Address - Country:US
Practice Address - Phone:314-534-8689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200122431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty