Provider Demographics
NPI:1760559918
Name:BRYANT, ROGER (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 WATERS EDGE LN
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2858
Mailing Address - Country:US
Mailing Address - Phone:757-686-5865
Mailing Address - Fax:
Practice Address - Street 1:1683 GILBERT ST STE 100
Practice Address - Street 2:NMCP - SARP
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511-2731
Practice Address - Country:US
Practice Address - Phone:757-444-8506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK691103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service