Provider Demographics
NPI:1659461697
Name:BRYAN, MARTHA JEAN (LCP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JEAN
Last Name:BRYAN
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:JEAN
Other - Last Name:GINNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCP
Mailing Address - Street 1:635 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3602
Mailing Address - Country:US
Mailing Address - Phone:316-660-7600
Mailing Address - Fax:316-383-7925
Practice Address - Street 1:7701 E KELLOGG DR
Practice Address - Street 2:STE. 300
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-1706
Practice Address - Country:US
Practice Address - Phone:316-660-9600
Practice Address - Fax:316-660-9660
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS040103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical