Provider Demographics
NPI:1760429088
Name:BRYANT, BONNIE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:L
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 W 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1024
Mailing Address - Country:US
Mailing Address - Phone:301-292-3994
Mailing Address - Fax:304-725-3461
Practice Address - Street 1:10312 OLD FORT RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-4123
Practice Address - Country:US
Practice Address - Phone:301-292-3994
Practice Address - Fax:304-725-3461
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002219103TC0700X
MD02802103TC0700X, 103TB0200X
VA0717000668106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
422021N75Medicare PIN