Provider Demographics
NPI:1619432093
Name:BRYANT, MARLO DESHAWN (LMHC,NCC)
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:DESHAWN
Last Name:BRYANT
Suffix:
Gender:M
Credentials:LMHC,NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14527 7TH ST
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33523-3102
Mailing Address - Country:US
Mailing Address - Phone:352-467-6014
Mailing Address - Fax:
Practice Address - Street 1:14527 7TH ST
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33523-3102
Practice Address - Country:US
Practice Address - Phone:352-467-6014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-10
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16696101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101YM0800XMedicaid