Provider Demographics
NPI:1750827028
Name:BRYAN, MICHELLE (RASAC1)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:RASAC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1639 BRUCE SMITH PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-7691
Mailing Address - Country:US
Mailing Address - Phone:417-257-1833
Mailing Address - Fax:417-256-0488
Practice Address - Street 1:1639 BRUCE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-7691
Practice Address - Country:US
Practice Address - Phone:417-257-1833
Practice Address - Fax:417-256-0488
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO9568101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)