Provider Demographics
NPI:1679184147
Name:BRYAN, MATTHEW CHRISTOPHER (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHRISTOPHER
Last Name:BRYAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 OSPREY CT
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9502
Mailing Address - Country:US
Mailing Address - Phone:915-873-5672
Mailing Address - Fax:
Practice Address - Street 1:185 OSPREY CT
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9502
Practice Address - Country:US
Practice Address - Phone:915-873-5672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2022-04111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical