Provider Demographics
NPI:1609073451
Name:BRYANT, DEBRA KAY (BCABA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:KAY
Last Name:BRYANT
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1092
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1092
Mailing Address - Country:US
Mailing Address - Phone:314-750-0068
Mailing Address - Fax:618-281-9219
Practice Address - Street 1:444 SOVEREIGN CT.
Practice Address - Street 2:SUITE A
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4432
Practice Address - Country:US
Practice Address - Phone:314-750-0068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0-05-1714174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist