Provider Demographics
NPI:1659010122
Name:BRYANT, KELLEY A
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:A
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 NYE RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-9133
Mailing Address - Country:US
Mailing Address - Phone:315-946-5722
Mailing Address - Fax:315-946-5726
Practice Address - Street 1:1519 NYE RD
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-9133
Practice Address - Country:US
Practice Address - Phone:315-946-5722
Practice Address - Fax:315-946-5726
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114037104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker